Physician's Coding Strategist-Consultation vs. office visit: Know the difference

Knowledge can pay off

Many practices are not clear about when they can bill Medicare for a consultation rather than a typical office visit. Since "consultations tend to be reimbursed at a higher rate than comparable office visits, understanding the differences can be to your advantage," notes Kent J. Moore, manager for reimbursement issues at the American Academy of Family Physicians (AAFP).

Moore says Medicare only pays for a consultation when all of the following criteria are met:

• 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 second opinion.

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

• 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, an order in the record, or a specific written request for the consultation.

Likewise, the consultant's report may consist of an appropriate entry in the common medical record. "In situations where the medical record is not shared, the request for a consultation may be documented in one of two ways," says Moore. 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. "When you're the consultant, you could bill a consultation for performing a postoperative evaluation if you didn't already perform the preoperative consultation," he advises.

If another physician in your group asks you for a consultation, or if 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," says Moore.

However, if you assume responsibility for management of a portion or all of a patient's condition during the postoperative period — such as for a local patient who receives surgery out of town — you cannot bill a consultation code, regardless of whether you performed the preoperative consultation. Instead, use the appropriate subsequent hospital care code or office visit code to bill your services, he says.

When a consultation turns into treatment

"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," says Moore.

According to Medicare, 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 turn, the receiving physician should bill an established or new patient office visit code, whichever is appropriate, rather than a consultation code. Any subsequent visits to manage a portion or all of the patient's care are then reported using a visit code, he notes.