Wiki Consultations

[MJD2019]

When coding for a consults, would the first visit with Gastroenterology be considered a consultation or would an E/M be used? I read that "the consulting physician’s advice as a guide, the attending/requesting physician intends to continue to treat the patient. If the requesting physician intends for the consulting physician to assume immediate care of the patient’s condition, the service is not a consultation, but instead a referral or transfer of care." So when or how does one determine if the visit was a transfer of care/referral or when a physician assumes immediate responsibility for a patient’s care? Does the provider doing that visit need to state they're taking the care over?

Scenario: Patient was referred to the GI clinic by PCP (APRN) for acute pancreatitis without necrosis. CT did not demonstrate pancreatitis. Lipase only slightly elevated at 83. Acute pancreatitis is unlikely the cause of her RUQ pain, and given her history of the RUQ pain and reports of occassional dyspepsia I will order an EGD to rule out PUD, gastritis, GERD. Biopsies for H. pylroi appreciated. Will also recheck Lipase to ensure it has returned to normal and Celiac serology. Will start the patient on a PPI.

The way I interpret the above scenario is that the PCP has transferred the care to another physician to take over the responsibility for managing the patient’s complete care for the condition. The 3 elements (request, reason and report) were met but the intention(s) of the visit isn't very clear.

Any information provided would be helpful and thank you in advance

 

[csperoni]

1) This does not seem like the CODING definition of consultation. For a consultation code, one requirement is the original provider is not sending the patient for treatment. They are sending the patient for the specialist to offer advice so the original provider may treat the condition. The medical provider definition of consultation is very, very, very different than the requirements to bill a consultation code. Even if your service meets 2 of 3 "R"s (request and reply), it does not appear to be a consultation service.
2) Even after multiple attempts at education by CMS regarding the coding requirements of consult codes, they determined 75% of billed consults were not actually consults. Based on this, CMS eliminated consult codes over 10 years ago.
3) Most commercial carriers have now followed suit. We used to keep a list of insurances that still allowed consults. Even within a carrier, depending on the type of plan, some plans covered and some did not. The list got so short we just decided rather than try to have 2 different sets of requirements for coding potential consultations, we would no longer bill consult codes.

Due to all of the above, I caution against the use of consultation codes at all. Unless it is 100% clear the plan covers consultation codes and 100% clear the service meets all requirements for consultation codes, E/M should be used. I'll also note with the 2021 updates, for a new patient it is certainly easier to meet 99204 than 99244. No more counting organ systems or bullet points. Acute illness with systemic symptoms and prescription issued = 99204. Took me 30 seconds to level the visit.

 

[MJD2019]

1) This does not seem like the CODING definition of consultation. For a consultation code, one requirement is the original provider is not sending the patient for treatment. They are sending the patient for the specialist to offer advice so the original provider may treat the condition. The medical provider definition of consultation is very, very, very different than the requirements to bill a consultation code. Even if your service meets 2 of 3 "R"s (request and reply), it does not appear to be a consultation service.
2) Even after multiple attempts at education by CMS regarding the coding requirements of consult codes, they determined 75% of billed consults were not actually consults. Based on this, CMS eliminated consult codes over 10 years ago.
3) Most commercial carriers have now followed suit. We used to keep a list of insurances that still allowed consults. Even within a carrier, depending on the type of plan, some plans covered and some did not. The list got so short we just decided rather than try to have 2 different sets of requirements for coding potential consultations, we would no longer bill consult codes.

Due to all of the above, I caution against the use of consultation codes at all. Unless it is 100% clear the plan covers consultation codes and 100% clear the service meets all requirements for consultation codes, E/M should be used. I'll also note with the 2021 updates, for a new patient it is certainly easier to meet 99204 than 99244. No more counting organ systems or bullet points. Acute illness with systemic symptoms and prescription issued = 99204. Took me 30 seconds to level the visit.

Thank you for helping me clear this up