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Consultation Codes - medical decision making

  1. Post Consultation Codes - medical decision making
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    When CMS nixed the reimbursement of consultation codes;the fact is, CMS is suggesting the fraudulent action of coding by the Consulting physician. The very relationship of the Primary provider to the Specialist is to provide a superior knowledge of disease management for medical decision making and medical neccessity.
    The Medical Record by both providers will read that a Consultation was requested and a Consultation was performed regarding the patient.
    The E/M codes do not touch the intensity of the higher knowledge sought from a specialist.

    CMS is urging and supporting fraudulent coding by medical professionals and seeking endorsement from AAPC to participate, which violates the very foundation and morals of my AAPC.

    Cathy Hodges, Overland Park, KS
    HCAPS Midwest Physicians

  2. #2
    Columbia, MO
    I do not see the fraudulent coding at all. CMS has decided that consulting services do not exist. If you read the release they submitted they indicated the reason for this was that based on results of audits there was rampant inappropriate billing of consultation services when the documentation does not support the service as a consult. They indicated that they had tried to educate provides on exactly what a consult was to be and how to communicate the nature of a consult and even gave the simple formula of the 3 Rs to follow. However after all of their efforts they felt that there was too much of a misunderstanding and therefor the designation of consultation service was dropped. The decision however came too late in the year for the codes to be deleted from the CPT book so they made a memo to inform the industry that CMS was labeling consultation codes invalid. There is no fraud involved with this. The system we work withing is constantly evolving and the authorities do reserve the right to implement and delete codes at any time. So I am not sure where you are seeing that it is fraudulent coding for us to follow updated directives from the regulating authorities in our industry. I am just curious how you see this.
    Last edited by mitchellde; 08-19-2010 at 08:19 PM.

    Debra A. Mitchell, MSPH, CPC-H

  3. Exclamation
    I hapen to agree with Debra. I have been coding for various specialties and MDs think passing in the halllway and being asked to see a PT while they are on rounds. Or that the ER MD calls the physician whom is on call. These instances are not consultations though referrrals they are. Just because a specialist is just that does not mean every PT that is sent from a primary care or ER is going to result in a qualified consulation, especially once the MD treats the PT and continues with follow up. I have argued till I was blue in the face with MDs and yet they still think "well, Ii am a surgeon!" Ceertainly he maybe, but it very unlikely a primary care MD is going to get the scalpal out and proceed with a surgical procedure there in the office, even if it happens that the DX is appendicitis. However on the other side of the subject a lot of specialties did get the bad end of the deal, such a pain mgt, cardiologist, neurologists, etc. But the fact is audits have proven beyond doubt the system was abused widely! So shame on those coders who billed it out of guidelines that were in place for what a "true" consultation is defined.

  4. #4
    Default Title of reports
    This is a silly question, but my surgeon is still calling his inpatient "requested" visits as Consultations. Will this be an issue if there is an audit? What would be the appropriate title for such visits?

  5. #5
    Milwaukee WI
    Default Call them whatever you like
    Our physicians also dictate "consultations" on some patients. Not ALL payers have stopped recognizing the consultation codes.

    No problem.

    F Tessa Bartels, CPC, CEMC

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