Urology Coding Alert

And regulators are paying close attention to these services

Coding consults and referrals is often confusing for even experienced coders. But 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. What's in a Name? Defining Consults and Referrals A consult is a service rendered to give an "opinion or advice" to a requesting physician about a patient's diagnosis or treatment. A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another.
 
In 1999, CPT Codes and CMS, in an attempt to clarify these criteria, stated that a transfer of care occurs when a physician asks, verbally or in writing, the urologist to assume "complete urological care" of the patient, and the urologist accepts to provide this patient care before and in advance of seeing the patient. Remember the Three R's But consultation criteria must be satisfied. There must be a request from a physician or other source; a reason for the request, with a recording or documentation of such in the medical record; and a separate written consultation report sent back to the requesting physician or other source.
 
A primary-care physician usually brings in a urologist for a consult, but a variety of sources can request a consult - podiatrists, chiropractors, clinical social workers, a physician assistant, or a nurse practitioner.
 
Note: A nurse cannot request a consultation for payment purposes.
 
Typically the requesting physician sends the patient to the specialist, the specialist provides his opinion concerning diagnosis and/or treatment and, at the conclusion of the consultation, sends the patient back to the requesting physician.
 
A consultation can be rendered for a new patient or an established patient. A urologist may see a patient in consultation and then decide after the visit to take over and render treatment. You can still code this first encounter as a consultation with follow-up visits as subsequent care.
 
A urologist may also render a consultation and order diagnostics tests, in which case you should still report the visit with a consultation code. But remember that all criteria for a consultation must be met and, most important, without a "request" for your opinion or advice, there can be no consultation.
 
Billing for a consultation when the service provided doesn't meet the definition of a consult can land a practice in hot water with the OIG and with their state attorney general [...]