Consultation Requests - Two Questions

maine4me

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I apologize for yet another question regarding consultations, however some questions regarding the request portion of the consultation requirements have been asked, on question one I am not sure of the answer, and question two my response is being disputed by a member of administration. Thank you in advance for helping me once again.



1. We have a breast surgeon who often will receive calls from the radiologists in our women's diagnostic center, stating that the patient had abnormal findings on the imaging and needs to see a surgeon. As the discussion went on, it seems that all patients with abnormal breast imaging are sent to the surgeons office as part of the process. So the question is, does the "referral" from the radiologists satisfy the request requirement in order to bill a consult? My gut feeling is that this would not meet the guidelines, since we would not be sending the report back to the radiologists, but rather to the patient's gynecologist or primary care physician.



2. There has been much discussion amongst our practice managers and administration regarding the fact with the dawn of EMR's and more online processes that a formal request is rarely received. I advised that the request for consultation does not have to be on paper, but can also be a verbal request, as long as both the consulting physician and the requesting physician document this in the patients chart. The question keeps coming up that the insurance referral should be considered a request for consultation. I completely disagree with this view, since just because an insurance referral is issued, this does not mean a consult request has been made. There has been some talk about if a patient is sent to the specialist office for a visit, that we create our own consult request form to send to the PCP or other referring physician to have them sign and indicate the desire for consultation and the opinion of the specialist based on his or her expertise. I guess I am looking for guidance from the group about whether the insurance referral can double as the request, and if not how other offices handle this type of situation?
 

thomas7331

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I agree with you in both of your examples in the post. A referral is not a consultation - the intent of a consultation is a request for an opinion, with the understanding that the information provided by the specialist will be supplied back to requestor who will use it and incorporate it into their own plan of care for that patient. If the requestor does not have the expectation that the patient will be coming back to them for additional treatment after seeing the specialist, then in my opinion it doesn't meet the definition of a consultation no matter how much paperwork you have in the chart.

When I used to teach coding ideas to providers, I would ask them did the referring provider say to the patient "you need to see a specialist for this, I recommend Dr. XX" or did they say "I'm not sure about this and would like to have Dr. XX take a look and give us their opinion"? If it's the former, it's a not a consultation; if it's the latter it is.
 

maine4me

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Thomas,

I am in complete agreement with your explanation. I guess the difficulty is how to distinguish between the two circumstances once the patient is scheduled and/or in the office. The practice administrator feels that anytime a new patient is seen by one of our specialty groups that this is definitely a consultation, and I have explained that without the 3 R's it would not qualify. The stumbling block seems to always be the documented request.

Do the providers you have trained simply ask the patient or do they have another process for determining if this is a request for consultation?
 

thomas7331

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Our doctors did not involve the patient in this - the patients don't necessarily know. I think the simplest way to spell it out is that this has to be a request coming from a provider who is overseeing the patient's care and will continue to do so after the consultation has been done. It's more straightforward in a hospital setting because the attending physician will order a specialist consultation to supplement their care plan and both the order and the consultant's report are clearly included in the patient's chart. But the concept is the same in the office.

I agree with you that the documentation of the request is key and that it (or the referring provider's order in the shared record) should clearly reflect that the provider is asking for an opinion about a specific problem, not just making a request for treatment. I've known practices that will require the referring provider to send over the written request to include in the chart so that the visits can be billed as consults. This in all likelihood will be sufficient to cover you in an audit but personally I think it is following the letter but not the spirit of the law, so to speak. I suspect it is partly the reason behind Medicare's decision to stop paying consultations altogether, and as we move into a time of increasingly coordinated care I expect more payers will do the same and that consultation codes will go the way of the dinosaurs.
 
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