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
Mary, CPC, COSC