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Consult Uh OH

  1. #1
    Red face Consult Uh OH
    Medical Coding Books
    Hello my fellow Coders,
    I am posting this underneath two forums because it applies to both and I need as much feedback as I can get.
    Yesterday I was thrown for a bit of a loop during a Medicare Webinar on consults that seemed to change what I have always been accustomed to. I am not new to coding however consults have been under quite a bit if scrutiny and I am trying to be as educated as possible so that I can educate my doctors as well.
    Here is my scenario and question:
    A patient presents to the ER with dysphagia. The ER doctor requests a GI consult. GI comes in and examines the patient (performs all the components of an E/M level). GI subsequently takes the patient to the endoscopy unit (or stays in the ER) and performs and EGD and removes a fish bone. The patient is discharged home with follow up instructions.

    Question: Does GI bill a consult code? Why or why not?

    PS: I know that a modifier would be needed on the E/M, and the procedural and dx coding my main focus is whether or not this is a true consult.

    Thank You in advance for sharing your thoughts and opinions with me.

    Kimm Hall CPC, CGCS, CMSCS
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  2. #2
    Default consult
    I would say yes, it's a consult. My reasoning is that it was at the request of Dr. ER, who felt a specialist should see the patient. Dr. GI examines the patient and decides at that point to do an EGD. He didn't know when he came in to see the patient that he would be doing an EGD, that decision was made at the time of the exam. So you have your request (Dr. ER), Dr. GI renders an opinion, and sends/documents a report.

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    I agree with Anna.

    Consultation Followed by Treatment

    A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.

    Medicare Chpt 12 30.6.10 B
    Rebecca CPC, CPMA, CEMC




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  4. #4
    Default
    I would agree with you both however I was told yesterday by the educational rep from medicare that it is not a consult. According t her her a consult is the request of advice or an opionion on how to treat a problem or symptom. The ER doctor is not asking for advice on how to treat the patient he is asking for the patient to be treated(per her this is a transfer of care). Also she states that an ER doctor does not meet the requirements for a consult because the specialist is not giving the care back to the ER doctor to manage (essentially they have treated the problem they were called for). This was after a long discussion and review with her of that very same section (Medicare Chpt 12 30.6.10 B ) of the manual. This totally blew away what I have always thought to be accurate. Your thoughts?
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  5. #5
    Default consultation
    Quote Originally Posted by KimmHall View Post
    I would agree with you both however I was told yesterday by the educational rep from medicare that it is not a consult. According t her her a consult is the request of advice or an opionion on how to treat a problem or symptom. The ER doctor is not asking for advice on how to treat the patient he is asking for the patient to be treated(per her this is a transfer of care). Also she states that an ER doctor does not meet the requirements for a consult because the specialist is not giving the care back to the ER doctor to manage (essentially they have treated the problem they were called for). This was after a long discussion and review with her of that very same section (Medicare Chpt 12 30.6.10 B ) of the manual. This totally blew away what I have always thought to be accurate. Your thoughts?
    My goodness. I'm afraid I don't agree with her. An emergency room DR can and does request consultations. He would be given back the treatment if the GI Dr. agreed that there would be no need of treatment by him. I have seen this happen. There are no guides I know of that say ER Dr's cannot do this. I do not agree about this being a transfer of care. DR GI didn't know until he came in what would happen. This is obviously controversial, but my opinion is that it's a consult. Until Dr. GI examines, he doesn't know what is wrong or what treatment will be rendered, if any.

  6. #6
    Location
    North Carolina
    Posts
    3,126
    Default
    Boy oh boy...this can become so gray. I suppose this is why Medicare is considering "doing away" with consultations. Here's my opinion. First of all, I have never been taught that an ER physician can't request a consult nor have I ever seen this in writing. Now...if this is a guideline exclusive to your region, that may be another story. To start the ball rolling, I would ask for the Medicare guideline that she is citing and ask to explicitly show you where an ER physician is removed from this protocol. I can, somewhat, understand her thinking about the "transfer of care" issue, but the GI physician can not render an opinion until he examines the patient. It makes me wonder if this "educator" is implying that the GI physician should be the admitting physician. If the ER physician is asking for the GI specialist to take over the care, I could see her point; however, to say that an ER physician can NEVER request a consult, I just can't digest this. You certainly have given me something to research today!!

    Ok guys...time to chime in on this one........
    Rebecca CPC, CPMA, CEMC




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  7. #7
    Location
    North Carolina
    Posts
    3,126
    Default
    Now...I want to clarify...If the ER physician is expecting the specialist to manage the care of this patient, I would agree that it would not be a consult. However, if the intent is to seek an opinion and it is properly documented, then I would have to agree that a consult is warranted. After all, the consulting specialist doesn't always render treatment. I was able to locate a citing from CPT Assistant...

    December 2005 page 10
    Coding Consultation:Questions and Answers

    Evaluation and Management: Consultations (Q&A)

    Question

    Question: Is it appropriate to report the Initial Inpatient Consultation codes (99251-99255) when a consultation is provided in the emergency department?

    AMA Comment

    AMA Comment: No. As stated in the Office or Other Outpatient Consultations guidelines, "The following codes are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department [emphasis added]." Therefore, if a consultation is provided in the emergency department, the appropriate Office or Other Outpatient Consultation code (99241-99245) should be reported
    Rebecca CPC, CPMA, CEMC




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  8. #8
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Check this link out:
    http://www.trailblazerhealth.com/Pub...0job%20aid.pdf
    I stand by my opinion that this scenario is not a consult.
    Lisa Bledsoe, CPC, CPMA

  9. #9
    Default consult
    Well, this is certainly a gray area. But, I still feel this could constitute a consult, if as has been pointed out, if all the correct documentation is there. There are no rules, or guidelines that say an ER physician cannot call for a consultation (at least that I know of). I also agree there are fine lines in the documentation for these codes; consultation vs referral or transfer of care. But, I also stand by my opinion that just because an ER Dr calls in another Dr. does not necessarily mean it's a transfer of care. It can and has been put back on him (DR ER) to take care of the patient after the specialist has examined and rendered his opinion. I think, as always, this will be a case by case basis. They cannot across the board say this isn't going to happen. Unless, or until they remove the consult codes altogether or put in writing that specific specialties/areas cannot request consults. Wow, this is something to think about. Thanks guys!

  10. #10
    Default
    Something else to think about.

    In your situation when the specialist doesn't treat the patient and sends them back to the ER doctor, you are basing the coding of a consult on the outcome of the visit. Consults are based on intent, not outcome. Any provider can get a transfer of care and refuse to continue care after seeing the patient. That doesn't make it a consult.

    Laura, CPC

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