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Thread: Consultation help

  1. #1

    Post Consultation help

    AAPC: Back to School
    I have a different understanding and interpretaion than my coworkers on billing consults in the hospital setting. They believe that as long as some one like a hospitialist or a primary care doctor has admited patient and writes an order, it is a consult. It does not matter how many times or how recent our specialist has seen the patient prior. I have example where the patient had chemo treatment a week prior ordered by our doctor, was admitted to the hospital for cancer dx. Hospitalist writes order for our doctor to see and was billed as a level four consult. I have been searching for documetation but I cannot find anything clear about consulting on established patient. They are meeting the three "R"s but this seems wrong. They claim that the hospitalist is the admitting and they are only a consultant in the hospital for most patients and are documenting in that manner. We all are looking at the same policies from Medicare and seeing different things.
    I was taught that unless the patient has an unrelated problem than it is not a consult, but of course primary care can do a consult on their patient prior to surgery?
    What guidelines are other clinics/providers using?

    Thank you so much!!

  2. #2


    In order to bill for a consultation, the rendering provider needs to receive a request from another qualified health care provider to see a patient for a specific problem. The request doesn't necessarily need to be a written request. It does, however need to be documented in the rendering provider's notes and it really should be documented in the requesting provider's notes (although we can only assume responsibility for our own provider). The consultation can be on a new or established patient. Your provider can only bill for one consultation per hospital stay. If your provider sees the patient today and performs a consultation and sees the patient again tomorrow, he/she can bill a subsequent hospital level based upon the documentation. The only time your provider should bill for another consultation is if he/she receives another request for consultation. If there isn't another request, there shouldn't be another consultation. We no longer have procedure codes for f/u consultations. Your provider should be following up with the requesting provider. If the record is shared, such as in a hospital setting, the note will suffice.

    I hope this clarifies your situation. Does anyone else have anything to add?


  3. #3

    Exclamation Consultation audits

    They are meeting all the requirements from CMS. They have the hospitalist admit their patient, and request the consult. They are technically following the rules. Their dictation is solid and through. My issue with these consults is I believe they should be consider transfer of care. They are already are treating the patient for the same diagnosis in the clinic. So for example patient is receiving chemotherapy treatment then two days later the patient is dehydrated. The patient presents to ER and is admitted. The hospitalist requests their oncologist to see patient. The requirements are met, but it seems wrong to me. We are looking at the guidelines from CMS and the providers are saying they are doing what is required. I say it is a transfer of care but they are reading you can still do consult and provide treatment if needed. Some doctors are providing several consults a month on the same patient same problem but different requesting. I can not find anything to support my opinion and they are open to what I am saying if I can prove it.
    If you google the phrase "Widespread Probe Review Results of Consultation Services" it is showing most consults audits are failing by well more than half.
    It is really concerning. Thanks for any help.

  4. #4


    While I wish we were not responsible for the "requesting" physician, in an in-patient setting there does have to be an order or documentation in the requesting provider's note.

    I think this link will help all of us to have a better understanding. I was not clear myself until this question was asked.

    Last edited by rjconnell; 06-09-2008 at 10:32 AM. Reason: Added link, removed incorrect info
    Rachel C. Ashley, CPC-E/M
    Houston, TX

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