Wiki Free consults help needed

[thejamesgang3@gmail.com]

I work for a 2 provider mental health practice that provides ketamine injections (not infusions) and Spravato treatment for patients with treatment resistant depression. We are also set up to through the state to certify patients who present with a qualifying condition for medical cannabis. We offer a free consult (typically 30-60 minutes) for those interested in these types of treatment. The owner and I have a difference in opinion on how we should be documenting these visits. My thinking is if we consult with someone and give an opinion on which treatment would be most effective/beneficial for a patients situation, we need to be creating an account for them in our system and documenting their consult. We have a "dummy" code for ketamine/spravato consults and a separate one for cannabis consults. Our system requires a diagnosis to be entered when posting services to a patients account. My provider feels that since he is not doing an actual intake, there is no reason for him to establish a diagnosis but he does create a note regarding the visit. From a billing and compliance standpoint, which one of us is correct? I feel that we need to use the "dummy" code to reflect the visit even if the patient doesn't come back for treatment and also for keeping track of his time, which he is not being compensated for. Any thoughts on the situation would be appreciated. Thanks!

 

[thomas7331]

From a compliance standpoint, if you are not billing anything, then there is no requirement to enter any codes into a billing system. Many providers do enter dummy codes for purposes of tracking provider activity and productivity for no-charge visits, but that is a business decision and not a legal requirement. If your practice owners feel that it is not worth the time and expense to do that, that is their choice.

The provider does need to accurately document the encounter in the patient's medical record and retain those records for the period of time required by law, but from you've said it sounds like they're already doing that.

But offering free consults is a questionable practice and that's something you might want to have a compliance specialist review. Offering free goods or services to patients who are covered by a payer plan can be considered giving them an 'inducement' to consume additional services, and in certain cases this could be illegal.

 

[SharonCollachi]

I would ask your Medical Board. Ours would not be happy with no diagnosis in the record. Billing records are irrelevant to treatment records.