Results 1 to 10 of 10

Consultation Codes

  1. #1
    Unhappy Consultation Codes
    Medical Coding Books
    Last week I wrote in to the forum asking for advise on coding for Employee Health Dept. Someone suggested that I review the May 2009 Coding Edge article on consultation's.
    I am more confused than before. Here is a example - PCP refers John Smith to see a Ortho specialist for severe lumbar spine condition. PCP will not be treating Mr. Smith for this condition but rather will let the Ortho. Specialist handle this problem. Is this a consultation or a new/est patient? Especially if the Ortho Specialist will be having Mr. Smith go for PT and then return for follow up care of this condition.

  2. #2

    As per my knowledge, this should be a consulation, because three R required to code consultation.

    R - Request
    R - Render
    R - Report.

    If PCP given a request letter & ortho CC the report to PCP, then it should be a consulation.

    could anyone confirm me


  3. #3
    Default consultation
    My opinion is that if the PCP is going to let the ortho handle the problem, it's no longer a consult but a transfer of care. It all depends on the intent when that patient goes to see the ortho. If the PCP is asking for opinions, such as "In your opinion as an orthopedic specialist, what treatment plan would you recommend"? then it's a consult because that request is there, the ortho will check the patient, then render his opinion back to the PCP, no matter what that opinion is. The ortho can then treat or recommend at this point. But, in your scenario, the PCP is saying "This patient has an ortho problem, treat him please". That's not asking for an opinion. That's asking him to treat.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

  4. #4
    Default Transfer of care, new or established patient
    It is all about intent. The PCP determined they were not able to treat this problem and sent the patient out with no intention of getting them back.

    This is why consults are so abused, you can document anything to look like a consult and thus meeting the "requirements" but if the intent is not there you don't have a consult.

    While a consultant can start treatment and ultimately take over care that is not the intent of the visit. The provider requesting the consult intends to continue treating unless the consultant advises otherwise.

    Laura, CPC, CEMC

  5. #5
    Default Consultation codes
    Thank you all for your replies. I will have to take another look at the records to determine intent. So am I correct to assume that if the PCP refers out to a specialist for them to handle this condition/diagnosis then it is not a consultation but rather a E/M code?
    Seems like this topic has different interputations based on what the PCP and specialist documentation is.

  6. #6
    North Carolina
    The intent of a consultation is to seek an opinion/advice regarding evaluation and/or management of a specific problem. If the specialist refers to the patient out for management of the condition, this would be a transfer of care.

    CMS definition: The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge

    If the intent is to seek an opinion from the consultant, the consultant can still initiate diagnostic services/treatment at the initial visit.

    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.

    If the visit is a true transfer of care:

    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.


  7. #7
    I just want to share with everyone a patient complaint I received yesterday.

    The patient doesn't want to pay for the office consult with one of my surgeons because he told her he doesn't do the surgery she needs and set her up for an appointment with a surgeon that does. The supervisor taking the complaint brought it to me to determine if the coding was correct before she enforced that services were rendered and there is nothing we can do, sorry insurance didn't cover it (deductible).

    I read the note, looked like a consult. PCP sends the patient to a surgeon for his opinion on how best to treat a chronic pain issue can they do surgery or not. Everything looked fine on our end.

    As I did further investigation, I found out the PCP did not send the patient to us, the PCP sent the patient to a neurosurgeon who told the patient she didn't do that type of surgery. Neurosurgeon didn't send her anywhere she just said sorry I can't help you. On her own the patient starts calling all the surgeons she can find in the hospital directory and ends up calling one of mine. She asked the office staff if the doctor "takes out ribs", the staff told her yes he does he can do your surgery. They make her an appointment. And as earlier stated my doctor documented this like a consult, sent copies of the notes to the PCP, the neurosurgeon, and the doctor he sent the patient to after him.

    This was not a consult. This is a specialist who thinks he is entitled to bill for consults because he is a specialist. I don't dispute the patient received services and does owe a balance, but consults cost more than new patients and I feel it should be dropped down to the appropriate new patient code and sent back to the insurance for reconsideration which is what I advised them needs to happen.

    This upsets me as both an auditor and a patient. It is very frustrating when I hear people make statements like "you can't be held responsible for other doctors documentation, if you document you did a consult they have to pay you for it". We wouldn't advise them to document additional elements of exam that didn't take place, or anything else for that matter. At least I hope no one would. So why would we advise them on how to make it look like a service it wasn't?

    I only advise them to document what they do and I am crossing my fingers the consults go away because I feel like I am in the minority when it comes to wanting to do it right not just make it look right.

    Laura, CPC, CEMC

  8. #8
    North Carolina
    Keep your chin're doing the right thing....One day...the light bulb will go off. Until what you do BEST...train, teach, direct....

    As for the 3 R's...

    Remember the three R's:

    Respect for self; Respect for others; and Responsibility for all your actions.

  9. #9
    Milwaukee WI
    Default Anybody looked at CPT 2010?
    I just got my CPT 2010 book and started going through it to look at changes. AMA has changed the wording in the guidelines for consultation. Seems to me an obvious attempt to counter CMS plan to stop recognizing consults (and to give credence to those specialists who complain that they are ALWAYS consulted because they are specialists).

    The new phrasing is: "A consultation is a type of evaluation and managmeent service provided by a physician at the request of another physicain or appropriate source to EITHER recommend care for a specific condition or problem, or to DETERMINE WHETHER TO ACCEPT responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem." (sorry my font colors/bold/underling isn't working so I used all CAPS to add emphasis)

    I'm as guilty as the next person of taking CMS view on things, but, in fact, the CPT is owned by AMA (not CMS). It will be interesting to see how this new guideline/definition is viewed by the payers.

    F Tessa Bartels, CPC, CEMC

  10. #10
    North Carolina
    Thanks for sharing Tessa. You are the 1st person that has pointed this me, anyhow. I can't wait to receive my CPT...

Similar Threads

  1. Consultation codes
    By skoch65 in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 02-02-2012, 01:11 PM
  2. Consultation Codes - medical decision making
    By chodges in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 10-06-2010, 01:55 PM
  3. consultation codes
    By paulavanderpool in forum Auditing General Discussion
    Replies: 5
    Last Post: 03-24-2010, 07:12 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.