Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 04, 2007 PDF

Look to CPT guidelines to avoid misconceptions

Are you missing out on billing some consults because of misconceptions about what qualifies? Here are some consult myths which Stacie Buck, vice president of Southeast Radiology Management and president of the Florida HIM Association, exposed in The Coding Institute-s recent audioconference, -Surefire Strategies for E/M Reimbursement in Your Radiology Practice-:

Myth 1: A consult request must come from a physician.

Reality: Medicare will accept consult requests from a doctor or non-physician practitioner (NPP). And CPT rules allow a consult request from other sources, including attorneys, physical therapists, chiropractors, social workers or insurance companies.

Note: Medicare won't cover a consult unless a doctor or NPP requests it. But you shouldn't assume that other payors will reject consults when the requests come from other sources, notes Buck. Not all payors follow Medicare guidelines, and in those cases you should apply CPT guidelines, she adds.

Myth 2: You can't bill a consult if the requesting physician already knows the patient's diagnosis.

Reality: CPT guidelines don't require a diagnosis to be unknown at the time of a consultation, says Buck. -The consultation could be for the purpose of assessing the best treatment option for the patient,- she explains. In this case, the requesting physician should note that he/she is seeking opinions or advice regarding treatment.

Myth 3: You can't request a consult from another physician of the same specialty or in the same practice.

Reality: Nothing in CPT or Medicare guidelines forbids consult requests from doctors in the same practice or specialty, says Buck.

But Medicare expects consult requests within the same practice to be rare, she adds. For same-practice consults, the physician performing the consult should have expertise in a medical area beyond the requesting doctor's scope and expertise, she notes.

Myth 4: You can't bill a consult unless the specialist performs a history and physical exam on the patient.

Reality: There may be times when a physician provides a consult that consists only of counseling and coordination of care.

The referring physician may ask the consultant -to review patient records and offer advice on treatment options for the patient- without examining the patient, says Buck.

In this case, you should choose the consult level based on the amount of time the physician spends providing these services. The record should include total face-to-face time or floor/unit time, plus a summary of the counseling and care coordination, says Buck.

For a CD or transcript of Buck's audioconference, go online to http://www.audioeducator.com/ .