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Our outside auditor said that the majority of our Ortho visit's should be consults. Would anyone agree with this ?


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Ortho Consults

An easy concept I teach my students, is that consults require 3 R's.


If all three of these are met, then you can bill a consult. CPT Consultation guidelines state that the physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. If the consultant assumes care, subsequent visits are E&M visits.
Milwaukee WI
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Depends on your practice

Well I would think whether you have consults or new patient visits might depend on the nature of your practice and/or the particular visit.

Most fracture treatments are NOT consults. Even though the PCP sent the patient to you, in most cases the fracture has already been diagnosed and the referring physician doesn't provide fracture care, so sends the patient to an orthopedic specialist. In other words the PCP is not asking you for an opinion on how HE should manage this problem, he's asking you to fix it.

On the other hand, if your practice specializes in "back pain" then you may have mostly consults - even if the result of that first evaluation is that you order MRI or other diagnostic tests, or set out a treatment plan that includes PT, OT and Rx.

Hope that helps. (And I hope you have that recommendation from the outside consultant in writing.)

F Tessa Bartels, CPC< CEMC
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This was posted last week on the DH forum by Margie Vaught...perhaps it can help shed some light on this subject:

This is an area, that gets addressed incorrectly many times - it does not matter if the patient has a diagnosis - it matters what is being ask of the requesting/referring provider. So if a patient was diagnosed with Afib that means the cardiologist can't report a consultation? It does not make sense, but everyone seems to jump on if the patient has a fracture you can't do a consultation - does the ED provider know how it should be treated? Does it need surgery? etc.

CPT® Assistant August 2001 Volume 11 Issue 8
"Is it appropriate to code a consultation when the diagnosis is already known by the requesting physician and/or by the consulting physician?

CPT coding guidelines do not require that the diagnosis be known or unknown at the time of the request for consultation. A consultation may be reported regardless of whether the diagnosis is known or unknown, provided the requirements for a consultation are met. The requirements are summarized below:

• CPT guidelines define a consultation as “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source.”

• The written or verbal request for a consult must be documented in the patient’s medical record.

• The consulting physician may initiate diagnostic or therapeutic services at the consultation or at a subsequent visit.

• The consultant’s opinion and any services ordered or performed must be documented in the medical record and communicated by written report to the requesting physician or other appropriate source.

Clinically, there are many situations where the patient’s physician has already established the patient’s diagnosis or condition, evaluates and/or treats the condition, and subsequently requests a consultation from another physician when the requesting physician determines “it may benefit or be helpful to the patient” to do so.1 Such a request is generally based on clinical observations considered by the requesting physician to merit consultation with another physician.

The decision to request a consultation rests solely with the requesting physician or other appropriate source. It is the clinical judgment of the requesting physician that establishes the need and medical necessity for a consultation, whether or not the diagnosis is known at the time of the request. The content and nature of the request may vary from case to case, based upon the requesting physician’s judgment, the patient’s condition, and the scope of service the requesting physician desires of the consulting physician. "

Both CPT and AAOS and CMS state you can bill and report an E/M service with fracture care:

AAOS said this year that if a decision for surgery is made the same day a patient is seen for a new problem, bill for an E/M with modifier 57 (decision for surgery) or 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Here is the language from the AAOS CPT Coding for Orthopaedic Surgery manual: "...if a patient is seen for the first time, or an established patient is seen for a new problem, and the ‘decision for surgery' is made the day of the procedure or the day before the procedure is performed, then the surgeon can report both the procedure code and an E/M code, using a 57 modifier or 25 modifier (payor specific) on the E/M code. The E/M service must meet the documentation guidelines for the level of service reported."

In addition, the AAOS manual now states the E/M service is separately reportable "whether a surgical procedure is performed in the operating room or the patient undergoes a ‘closed treatment' with or without manipulation in a non-facility setting (e.g., office or emergency department)."

Separately, the American Medical Association (AMA) confirmed that if the E/M service is supported (i.e., it meets the required key components/counseling), it could be reported.

The following example was supplied to both AAOS and CPT/AMA: "Patient presents to office with nondisplaced Colles fracture. Provider does an expanded-focus history and examination, and determines it needs closed treatment without manipulation and a cast is applied."

Both AMA and AAOS confirmed it would be appropriate in this case for the provider to report 99202-57 or 99213-57 along with 25600, since the initial decision was made during the visit to provide a global service.

You'll want to remind your physicians to fully document the E/M visit, in order to support billing the E/M code - and expect to have to appeal this.

"I would recommend documenting the E/M visit as a separate paragraph from the description of the fracture care," says PCPS Technical Advisor Thomas Kent. "This will be documentation that you will need to fully support the appeal for the probably inevitable payment denial."

Margie Scalley Vaught, CPC, CPC-H, CCS-P, MCS-P, ACS-EM, ACS-OR
Healthcare Consultant



Knoxville, TN
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How to document a "verbal" request for consultations

I read alot of posts about making sure the request for consultation is in the patient's medical record. My confusion is when I read that a consultation request can be made verbally, but how do we document that.

Right now, when a physician's office calls our appointment desk and requests and appointment with one of our physicians our girls make a note that the patient was referred by "Dr _____". That note prints our on our charge ticket and then the physician dicatates that the patient was sent by "Dr ____". To me that is just not enough information.

I think we should get the request in writting. To my knowledge when an audit is done on a consultation code the referring physician's record could become part of the audit as well. If we are only getting the request over the phone then we have no proof that the referring physician documented his record appropriately.

My opinion is that we should have the referring physician's office fill out a request in writting and check off whether he/she is sending the patient for an opinion/advise or whether he/she is wanting to transfer the patient's care to us. At that point there would be no question as to what the referring physician's intentions are and intent is the big question.

How does everyone else handle this?