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Consult vs Follow up in the same practice

  1. #1
    Loma Linda
    Default Consult vs Follow up in the same practice
    Medical Coding Books
    "OMG" Need help!
    I work for a multi speciality orthopedic group and I am having a problem with when I am able to charge a consult vs a follow up when our physicians are referring with in the group.
    Patient was scheduled to see one of our spine specialists for the back (first visit ever to our clinic). When the patient was being seen by the doctor, he told the physician that he has no problems with his back his main complaint is of bilateral knee pain. Our physician went ahead and assesed the patient for his knees because he was not going to send the patient away without any type of care. The spine physician came to the conclusion that this problem with the knees was out of his scope of practice and thus referred to one of our joint (knee) specialists for a consult. The patients medical group is stating that it is not a consult it would be a follow up visit since the patient has already been assesed for the same problem by the other physican. But I am following the Medicare guidelines for 2006 and it states:
    [I]"Medicare may pay for a consultation if one physician or qualified NPP in a group practive requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional's knowledge. A consultation service cannot be reported on every patient as a routine practive between physicians and qualified Npps within a group practice setting."[/I]
    I had also consulted one of my co-workers who is also a CPC and she said that we were not able to charge a consult that it would be a follow up visit. But I am just following what the Medicare 2006 guidelines state and I had also found an article from the American College of Physicians that also states the same thing that Medicare states. Can someone help me out in understanding how to deal with this situation?
    Also, if I have a patient that comes into see one of our physicans for a problem and then the physician then wants to refer to one of our other physicans for the same problem because it is out of his scope of practice how would this be coded? I just want to make sure that I am coding this correctly for future as well. Any and all responses would be helpful and if anyone has any articles, websites anything that shows the guidelines and the correct way of coding consults for referring within the same group it would be very helpful. Thank you

  2. #2
    Default I agree
    I agree with your following the CMS regs about this and had this very same scenario come up recently in one of our offices. A consult can be requested by one group member from another who has more expertise in a given area and coded as such. The consult code should be allowed if there is 1) the request for advice/opinion 2) proof of care rendered (i.e. an office note) and 3) a note back to the "requesting" physician.
    Belinda S. Frisch, CPC, CEMC
    Author of "Correct Coding for Medicare, Compliance, and Reimbursement"

  3. #3
    Yes, I have seen this too. Sometimes payers are looking for sub-specialties & the credentials to go with in order to consider it for reimbursement. Good luck.
    Evangelina Frohna, CPC, CEMC

  4. Default
    According to the Medicare Claims Processing Manual- 30.6.10 - Consultation Services (Codes 99241 - 99255)
    E. Consultations Requested by Members of Same Group
    Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

    As long as the documentation supports the consult and all of the consult rules are followed you should be all set.

  5. #5
    Milwaukee WI
    Default Consult vs transfer of care
    Is the "Spine doctor" actually going to continue to see the patient and manage his knee problems? If so, then he may be requesting a consult from the Knee specialist in the practice.

    If you had a patient with spine problems and the spine doctor asked the knee doctor for his opinion on whether and how the patient's knee problems were affecting the management of his spine problems, THEN it would definitely be a consult.

    However, from your description, it sounds as if the spine doctor was referring (i.e. transferring care) to the knee specialist because the patient's problem was his knees and not his spine at all. It doesn't sound like the spine specialist will continue to see this patient. So I would bill an established patient visit for all additional visits in your clinic.

    F Tessa Bartels, CPC-E/M

  6. #6
    Loma Linda
    But in the medicare guidelines it states that if it is beyond that physicians expertise then the physician is able to charge a consult?

  7. #7
    Milwaukee WI
    Default IF it IS a consult
    Yes, Amzie, that is correct .. Medicare specifically states: "If one physician ... in a group .... requests a consultation from another." NOTE the important phrase "Requests a consultation." From your description it does not appear that the visit to the knee specialist was a consult so much as a transfer of care.

    It's important to understand that a a referral is not the same thing as a consult.

    A consult is done when one provider requests the advice or opinion of a second provider in the treatment/management of a particular problem. A referral (i.e. new patient or established patient visit) is done when one provider sends the patient to another provider for treatment of the problem.

    As your reported the circumstances, it does not seem as if the spine doctor is going to continue to treat/manage the patient at all. He is transferring care to the knee specialist who will take over treatment. The knee doctor's first visit with the patient is NOT a consult, it is an established patient visit.

    Your co-worker was correct; charge only the established patient (i.e. follow-up) visit for the knee specialist.

    F Tessa Bartels, CPC, CPC-E/M

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