Part B Insider (Multispecialty) Coding Alert

Published on Tue Mar 28, 2006 PDF

7 tips for complying with changed consult rules

Consults used to have three R's for documentation: Request, Render and Report. Now there's a fourth R: You have to indicate the Reason for the consult in both the requesting and consulting physician's files.

Complying with CMS' new rules on consult documentation will be a challenge, but experts offer the following tips:

• Document, then consult: It's not enough for the requesting physician's file to have the consulting physician's report after the fact. The request must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi with CRN Healthcare Solutions in Tinton Falls, NJ. If your doctor performs consults, you should educate the requesting doctor's staff about this new requirement. And you may consider sending the requester ordering slips, similar to the ones radiologists and clinical labs use.

• Standardize requests: Create a form that you can fax to the requesting physician's office for documentation of the reason for the request, advises Patricia Trites with Compliance Resources in Augusta, MI. The requesting physician can keep this form in the medical record.

• Separate report: Make sure the consulting physician writes a separate report of his/her findings and opinion, says Trites. Send that report to the requesting physician. In the inpatient setting this report can go into the same medical record for the patient, but in the outpatient setting carriers have instructed that this must be a separate record.

Same Group Consults Now Easier--But Riskier

• Be careful: It's always been true that a physician could request a consult from a colleague in the same group, but CMS has highlighted this fact, says Terry Fletcher, a healthcare coding consultant in Laguna Beach, CA. But this clarification adds to the pressure on physicians to make sure they're not making frivolous consults within the same group.

• Don't churn: Some practices have had a protocol where patients will come in to see Dr. A, and Dr. A automatically sends the patient to see Dr. B, according to Eric Sandhusen, director of compliance for the Columbia University department of surgery in New York. The feds will "see it as a sort of churning."

• Avoid transfers: Be especially careful to avoid transfers of care with consults by physicians in the same group, advises Nancy Reading with Cedar Edge Medical Coding and Reimbursement in Centerfield, UT. Take, for example, a group of neurosurgeons where one provider specializes in spine surgery and another specializes in skull-base work. An existing patient comes in with headaches, and the MRI shows a tumor that the spine surgeon doesn't feel qualified to handle. Since the spine surgeon is sending the patient to the other physician to care for this new problem, it's probably not a consult, she advises.

Another example: A physician sends a patient to a colleague who has specialized expertise in the management of a particular disease process. The requesting physician has exhausted all known treatment options and wants the consultant's opinion on treatment options. "This would certainly stand up as a request for opinion," says Reading.

• Return to sender: The consulting physician should make a point of returning the patient to the requesting physician, Cobuzzi says. This shows that the consult wasn't a transfer of care. Returning the patient also makes it possible for the physician to bill for another consult if the requesting physician needs more information about that patient  in the future.