Physician's Coding Strategist:

Bill for consultations, office visits correctly

Many practices are not clear on when they can bill Medicare for a consultation rather than a typical office visit. Because "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) in Leawood, KS.

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

  • A 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.
  • A 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;
  • 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.

"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.
  • The consulting physician can refer to the request in his or her documentation notes.

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," Moore advises.

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," 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.

"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," Moore says. 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," according to Medicare.

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.

Other experts note that physician consultants can initiate diagnostic and/or therapeutic service as the same or a subsequent consultation visit.

"The phrase at the same or subsequent visit’ clarifies that physicians can report a consultation even if they initiate treatment — assuming the criteria for billing a consultation have been met," says Brett Baker, a reimbursement expert with the American College of Physicians - American Society of Internal Medicine (ACP-ASIM) in Philadelphia.

If you assume responsibility for any or all of a patient’s care, however, you should not use CPT consultation codes for any other visits, says Baker. Instead, use the subsequent hospital care codes in an inpatient setting and established-patient office visit codes in an outpatient venue. Also, be sure to document the request for a consult in the patient’s medical record.

Physician consultants also should send the requesting doctor a written report detailing their observations and any resulting suggested or rendered diagnostic and/or therapeutic services.