Part B Insider (Multispecialty) Coding Alert

Published on Wed Aug 26, 2009 PDF

Document the consults as if an outside physician performed them.

Question: I have an ob-gyn practice that wants to bill consults within their same group. They all share the same tax ID but have different sub-specialties. They want to refer patients to each other and then bill out consults. Is this possible? If so, could you point me to the source document?

Answer: Yes, they can -- provided the following situations are true:

• The ob-gyn whose advice the other physician requests has more expertise than the initial physician.

• The visit meets the standard criteria for consults.

Consult criteria: The Medicare Claims Processing  Manual (MCPM), Chapter 12, Section 30.6.10, states, "A consultation ... is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician." But you shouldn't just look at that statement and assume that every request for an opinion warrants the consult codes (99241-99255).

The MCPM goes on to state, "A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician."

The five R's of a consultation are:

• Reason: Both the requesting and consulting physician must document a medically necessary reason and request for a consultation.

• Request: The request must come from another physician or qualified nonphysician practitioner.

• Review and Render: The consultant must review medical records that may have been provided by the requesting physician and then render the history, exam, and findings.

• Recommendations and Report: The consultant must issue a separate written report of his findings and recommendations for treatment to the requesting source, even though both providers are in the same office.

• Return (recommended by experts): To further show that a transfer of care didn't initially occur prior to the consultation request, the consultant should send the patient back to the referring physician after treatment ends.

Heads up: You can see the Medicare information on this topic by accessing www.cms.hhs.gov/manuals/downloads/clm104c12.pdf and scrolling to page 55.