Orthopedic Coding Alert

Question: How specific must a non-Medicare consult request be? I know there must be a specific reason for the request, but does the request have to specify by name the physician who should provide the consult?

Georgia Subscriber

Answer: Although a requesting physician certainly may request a consult from a particular specialist, this isn’t required. Neither AMA nor CMS guidelines state that the consultation request must specifically name the physician who provides the consult.

Theoretically, as long as the request specifies the problem, any physician with the expertise to provide his opinion may provide the consultation service. The requesting physician might only send a patient to a particular practice, for instance, rather than to an individual physician, for consultation.

But remember, to report a consult service, your orthopedist must meet all the requirements for that code set. He must document the following, at least:

• Request from a qualified healthcare provider
• Reason for the consult
• Render the consult service
• Report back to the requesting provider.

If your physician does not meet these requirements, you should report an office visit code (99201-99215).

Also keep in mind that if the patient’s primary-care physician merely stated that the patient should see an orthopedist, that would more likely be a transfer of care rather than a consult, and you would likely code for an office visit.