Physician's Coding Strategist-New rules apply to office visits, consultations

Avoid trouble: Know the difference

If you have not already, you need to update your reference manuals to account for Medi care's new clarifications of when it will pay for a consultation as compared to an office visit.

"Its vital to understand the changes since consultations tend to be reimbursed at a higher rate than comparable office visits," emphasizes Kent J. Moore, manager for reimbursement issues at the American Academy of Family Physicians in Leawood, KS.

According to Moore, Medicare now pays for a consultation only when all of the following criteria are met:

1. The service is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it's a patient-generated confirmatory consultation; i.e., a second opinion).

2. The request and need for the consultation are documented in the patient's medical record.

3. After the consultation, the consultant prepares a written report of his or her findings and provides it to the referring physician.

If the referring physician and consultant share the medical record, the request for a consult must be documented in one of three ways:

• as part of a plan in the referring physician's progress note;

• as an order in the record;

• as a specific written request for the consultation.

Likewise, the consultant's report may consist of an appropriate entry in the common medical record.

When the medical record is not shared, the request for a consultation may be documented in one of two ways. The consultant's record may include either a written request from the referring physician or a specific reference to the request. In either case, the consultation report should be a separate document supplied to the referring physician, says Moore.

When you consult

When you are the consultant, you could bill a consultation for performing a postoperative evaluation if you didn't already perform the preoperative consultation, he notes.

If another physician in your group asks you for a consultation or a surgeon asks you to perform a preoperative consultation, Medicare will reimburse you for a consultation as long as the previously mentioned criteria for use of the consultation codes are met.

It is also possible to bill a consultation code for performing a postoperative evaluation at a surgeon's request, but only if you did not already perform the preoperative consultation.

However, if you assume responsibility for management of a portion or all of a patient's condition during the postoperative period (such as the management of a local patient who receives surgery out of town), you may not bill a consultation code, regardless of whether you performed the preoperative consultation. Rather, you should use the appropriate subsequent hospital care code or office visit code to bill your services, Moore recommends.

If the criteria for a consultation are met, a consultant may bill an encounter as a consultation even if he or she initiates treatment, unless a transfer of care occurs.

A transfer of care occurs "when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance."

In such a case, the receiving physician should bill an established or new patient office visit code, whichever is appropriate, rather than a consultation code, Moore says.

Any subsequent visits to manage a portion or all of the patient's care should be reported using a visit code.

When it comes to consultations, Brett Baker, a reimbursement expert with the American College of Physicians-American Society of Internal Medi cine in Philadelphia, also notes that physician consultants may initiate diagnostic and/or therapeutic services at the same or subsequent visit. The phrase "at the same or subsequent visit" clarifies that physicians can report a consultation even if they initiate treatment (assuming that the criteria for billing a consultation are met).

However, if you assume responsibility for all or a portion of the patient's care, "do not use CPT consultation codes for subsequent visits," Baker warns. Instead, use the subsequent hospital care codes (99231-99233) in the inpatient setting and the established-patient office visit codes (99211-99215) in the outpatient setting, he advises.

Also, he says a physician request for an opinion from a consultant may be verbal or written. However, it must be documented in the patient's medical record.

Additionally, remember that physician consultants must now send a written report detailing their opinions and any diagnostic and/or therapeutic services to requesting physicians, says Baker.