Pediatric Coding Alert

... and Avoid OIG Scrutiny and Carrier Audits Even the most experienced coders have difficulty differentiating consults and referrals. However, with increasing attention being paid to consultations by the Department of Health and Human Services' Office of the Inspector General (OIG) and private-carrier auditors, you need to be crystal-clear on the rules for coding this service. Pediatricians function as their patients' primary-care physicians, overseeing and coordinating all of their healthcare. As such, a pediatrician is often the physician who initiates a request for a consult or transfer of service (referral) on behalf of his patient. For example, a pediatrician might request the assistance of a pediatric urologist for a patient with possible renal disease. There are also situations in which a pediatrician may be called on to "consult" on his own patients (or those of other physicians). For example, a specialist providing ongoing treatment to a patient for a specific problem schedules the patient for surgery. The specialist requests that the pediatrician perform a preoperative "clearance" physical exam to ensure that the patient is capable of undergoing surgery. When coding referrals and consults, the devil (as usual) is in the details: How the request is worded, documented and reported must align correctly with CMS guidelines, or else your hard work will earn you nothing. Understanding both sides of the equation -how to ask for a consult or referral and how to code one if you deliver it - enables you to provide a great service for your and your colleagues' practices: clean billing. What's in a Name: Defining Consults and Referrals "A consult is a service rendered to give an opinion to a requesting physician about a patient's condition," says Kristine D. Eckis, CMM, CPC, president of The Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. "A referral is the transfer of responsibility for a patient's care from one physician to another."

The intent of the visit is key for defining consultations, says Jennifer Swindle, RHIT, CCS-P, CPC, CCP, coding reimbursement services supervisor for a multi-specialty 150-physician clinic in Lafayette, Ind. "The physician who requests the consult is seeking the evaluation and opinion of another," she says. "The consultant may or may not provide treatment at this visit, but the intent of the visit was for his or her opinion."

Swindle finds it helpful to think of consults as a "circle" of care. The requesting physician sends the patient to the specialist, and the specialist provides evaluation and opinion and, at the conclusion of the consultation, sends the patient back to the requesting physician. The specialist also sends to the requesting physician a written report of his or her findings and any treatment that may have been rendered. [...]