Consultation auditing help, please

jawilmes

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:confused: I have a different understanding and interpretation than my coworkers on billing consults in the hospital setting. They believe that as long as someone like a hospitalist or a primary care doctor has admitted patient and writes an order, it is a consult. It does not matter how many times or how recent our specialist has seen the patient prior. I have been searching for documentation but I cannot find anything clear about consulting on established patient. They are meeting the three "R"s but this seems wrong. They claim that the hospitalist is the admitting and they are only a consultant in the hospital for most patients and are documenting in that manner. We all are looking at the same policies from Medicare and seeing different things. If you Google the phrase "Widespread Probe Review Results of Consultation Services" it is showing most consults audits are failing by well more than half. So there must be significant confusion.
I was taught that unless the patient has an unrelated problem than it is not a consult, but of course primary care can do a consult on their patient prior to surgery?
They are meeting all the requirements from CMS. They have the hospitalist admit their patient, and request the consult. They are technically following the rules. Their dictation is solid and through. My issue with these consults is I believe they should be charged as transfer of care. They are already are treating the patient for the same diagnosis in the clinic. So for example patient is receiving chemotherapy treatment then two days later the patient is dehydrated. The patient presents to ER and is admitted. The hospitalist requests the patient's oncologist to see the patient. The requirements are met, but it seems wrong. We are looking at the guidelines from CMS and the providers are saying they are doing what is required. I say it is a transfer of care but they are reading you can still do consult and provide treatment if needed. Some doctors are providing several consults a month on the same patient same problem but different requesting. I cannot find anything to support my opinion and they are open to what I am saying if I can prove it.
Thanks for any help.
 

Lisa Bledsoe

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You are absolutely correct. Unless they are being consulted on a new/different diagnosis, they cannot code a consult. If they routinely address the same problems in the office, it is NOT a consultation. The only deviation from this is the consultation prior to surgery because the surgeon is requesting the provider's opinion as to whether or not the patient is stable enough to udergo surgery.
 
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