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Thread: Consult Billing-Help

  1. #1

    Default Consult Billing-Help

    AAPC: Back to School
    Wondering if someone would be kind enough to help
    me I work for a general surgeon and he does lots of
    hospital consults - I do not understand the 4 R's
    I printed the score sheets out from the medicare site and
    still do not understand. My doc. gives me the codes; but
    I was wondering if there is a document that clearly states
    what is needed to bill out a 99255 etc etc. Thank you Deb,CPC

  2. #2

    Default Consult Billing Help

    I have always gone by 3 R's Request, Reason, Response, The request should be documented by the consultant in the pt's record and included in the requesting phys. plan of care. The reason for the consult should also be documented.

    The consultant should sent a written report of their findings to the referring physician.

    To document a high level consult the physician must document a complete history, complete exam and high level of decision making. If time is used it is 110.minutes You can get the guidelines @ cms.gov

    hope this helps you

  3. #3
    Join Date
    Apr 2007
    North Carolina



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


    A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record


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




    Below is a clinical example- 99255 requires a comprehensive history, comprehensive exam and MDM of high complexity


    Now...there are other factors that can be considered. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient.

    Also...as for sharing the information with the requesting provider...
    Consultation Report

    A written report shall be furnished to the requesting physician or qualified NPP.

    In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP’s progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.

    In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant’s records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.

    In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant’s report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.

    This can seem overwhelming but the links provided should answer most of your questions. Hope this helps~

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Consult vs Hospital Visit

    If your surgeon is being called to operate (clear need for surgery already identified by "requesting/referring" physician), then he has a hospital visit, not a consultation. If major surgery takes place within 24 hours be sure to add the -57 modifier to the E/M service.

    If your surgeon is being asked to consult on a case, and then, as a result of his evaluation of the patient determines that surgery is needed, and that surgery takes place within 24 hours of the consultation, then be sure to add the -57 modifier (decision for surgery) to the appropriate consult code.

    Our hospital record requires that the requesting physician place an "order" for the consult in the patient's chart. This is electronically available to our office, so we can always verify that this was a consult request vs a transfer of care.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 04-06-2009 at 02:37 PM.

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