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Consultation Request in Writing

  1. Default Consultation Request in Writing
    Medical Coding Books
    Since we are dependent on clarifying the intent of the physician sending the patient to us as in regard to whether it is a consultation or not, are we "safe" if we send them a form to check off their intent, "transfer of care" or "consultation". Could the consultation still be disallowed if the auditor did not feel it was a consultation even though the referring doctor answered our query. Many doctors in our area just give our number out to their patients, and we are often not sure of intent of the referring doctor. We are always struggling with this issue.



  2. Default Consultation
    This is from our Medicare Contractor:

    Contractors pay for reasonable and medically necessary consultation services when all of the following criteria are met:

    A consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source; and

    A request for consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) should be documented by the consultant in the patient's medical record; and

    After the consultation is provided, the consultant should prepare a written report of his/her findings and recommendations, which must be provided to the referring physician.

    If your service doesn't meet these criteria, then the service isn't a consult. It is a new patient E & M visit. The auditors will request records from the referring physician to verify this. Also, insurance company auditors will decide what code should have been used, in terms of coding. In fact, many insurance companies are employing CPC or CCS-P certified personell to conduct audits.Be careful, get educated (go to seminars and read the information on the CMS and Contractor's website) and follow the rules.

  3. Default
    I appreciate your reply, but I guess that my concern is that probably 9 out of 10 doctors that we deal with consider or call their request a consultation. They tend to call it a consult even if they send the patient to us for a specific problem, hernia, gallbladder, etc. Isn't it all about the intent of the referring doctor or the wording of the referring physican's request as to whether they want another opinion of the surgeon.



  4. #4
    I would think the reason for the visit should clarify what they doctor is wanting, because your right it is about intent. The word consultation is used as a lay term to mean initial visit. Unfortunately a lot of providers don't know there is a difference in coding terms.

    If they are just sending them to your surgeon because they don't provide those services ie colonoscopy, hernia repair, etc and just expect your providers to do the procedure then that would be a transfer of care.

    If they aren't sure what they should do and are asking for an opinion as to whether surgery is an option or not then that would be a consult.

    Good luck getting clarification from the other providers,

    Laura, CPC

  5. #5
    Milwaukee WI
    Default Intent of the requesting/referring physician
    De - you are right that the key factor is the intent of the physician to sends the patient to you. This is frustrating for everyone because the physician who is seeing the patient is not in control of HOW the patient came to see him/her, but is trying to code based on what s/he thinks the original physician wants.

    You stated that many physicians just give your phone number to the patient - these are probably NOT consults. For example - patient has a hernia and the PCP sends the patient to surgeon to get this taken care of. That's a transfer of care.

    On the other hand, say the PCP sees a patient with persistent GI problems and vague, recurring belly ache. Thinks patient might have an obstruction or ??. So he sends patient to a gastroenterologist for a consultation. Ideally there should be a physician-office-to-physician-office communication outlining what is concerning the PCP and requesting a consultation (advice/opinion on how to handle this problem). The gastro doc may evaluate and determine that surgery is warranted. That first visit is STILL a consult.

    All this is further complicated by the fact that whatever the PCP calls the "referral" or "request for consult" it doesn't impact the PCP's coding or reimbursement in any way. It only impacts the "consulting" physician - who has no control over the "requesting" physician's intent. S I G H

    Anyway, I hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. #6
    North Carolina

    I completely understand your dilemma. Here was my scenerio for the week...

    Patient presents to ER for fracture/sprain. ER physician renders treatment and requests that the patient follow up with our orthopedic provider (in office). When the patient arrived to the office, the visit was charged as a consult. This is clearly not a consult. Not only was the ER physician NOT asking for an opinion but this was a transfer of care. Guidelines, regulations, emails..... were provided in order to educate everyone. Even with Medicare Chapter 12 in hand, it was still an arm wrestling match.

    Examples That Do Not Meet the Criteria for Consultation Services
    EXAMPLE 1: Standing orders in the medical record for consultations.
    EXAMPLE 2: No order for a consultation.
    EXAMPLE 3: No written report of a consultation.
    EXAMPLE 4: The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code

    Transfer of Care
    A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
    When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.
    In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.

    Good luck...This is never an easy task.
    Rebecca CPC, CPMA, CEMC

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