The Three Rs of Consultation
By Faith C. M. McNicholas, CPC, CDERC, PCS
Historically for most practices, consultations (CPT Codes 99241 – 99245) have been a source of occasional confusion. Failing to distinguish a consultation from other Evaluation &
Management (E/M) services could cost your practice thousands of dollars.
Over the past few years, the Centers for Medicare and Medicaid Services (CMS) has clarified the consultation section of the Medicare Claims Processing Manual. Unfortunately, in that time, further confusion has cropped up over what a consultation is and who should request or perform one.
This article will help clarify the confusion. Some pointers to use when reporting a consultation: First, establish how the patient came to the office. Was the patient sent by a physician or appropriate source, neighbor, Internet search, drive-by, friend, etc? The answer to this crucial question – along with other contributing factors – will determine whether a visit qualifies to be reported as a consultation or other E/M encounter.
When a patient gets a recommendation from a neighbor, friend, drive-by, Internet search etc. this encounter must be reported with the appropriate new or established level of E/M service. However, if the patient states that a physician or other appropriate source asked them to see Dr. Wright, a few things have to be established in order for Dr. Wright to meet the requirements and report this encounter with the appropriate level of consultation code.
Physicians need to understand the additional documentation requirements necessary to satisfy an encounter reported as a consultation as opposed to other E/M services. To do this, it helps to remember the 3 Rs of consultation: request, reason and response.
1. Request
A consultation service is distinguished from other E/M services based on the intent of the requesting professional. According to the
Medicare Claims Processing Manual, “The intent of a consultation service is that a physician or
qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient
because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.”
The intent for a consultation is demonstrated by a written or verbal request from the professional seeking a consultation and not by the patient stating “Dr. Young told me to make an appointment with you.”
The critical point to note is that the requesting physician is not asking for help in caring for the patient but rather requesting for the consulting physician or NPP to render an opinion or advice.
Physician office staff should get accustomed to asking requesting professionals to provide a ‘written request for consultation’ that the patients can present at the time of encounter.
(Need a copy of a dual documentation request form? Drop us a note at
www.coraclebilling.com)
Who is the “other appropriate source?”
This question was addressed by AMA/CPT in the January 2006 issue of the AMA publication cpt® Assistant. The examples given of “other appropriate sources” include:
attorney, chiropractors, insurance company, nurse practitioner, occupational therapist, physical therapist, physician assistant, psychologist, social worker or speech-language therapist.
2. Reason
The requesting professional needs to provide a reason for the consultation. An example would be where Dr. Wright is an expert in Endocrinology and Dr. Young, an internist, sends his patient to Dr. Wright to determine whether a change in his/her current plan of care might benefit the patient. Dr. Wright may even make a change to the patient’s regimen during the visit. This encounter can be reported as a consultation because the request from Dr. Young was for an opinion or advice and not a transfer of care. The expert (consulting) professional (Dr. Wright) will provide a report to the requesting professional (Dr. Young) providing his/her opinion or advice.
Who can perform a consultation?
Medicare allows a non-physician provider (NPP) to perform a consultation service as long as that service is within the scope of practice and licensure requirements for the NPP within that particular state. However, physicians should be aware that Medicare will not cover a second-opinion encounter to satisfy a third-party payer requirement. Caution should be exercised before providing third-party consultation. Office staff should verify with the payer beforehand to confirm coverage of service. Modifier ‘-32’ can then be appended to the E/M consultation code for third-party
requests.
Assuming, in the case above, Dr. Wright and Dr. Young are in the same practice, Dr. Young may request a consultation from Dr. Wright because Dr. Wright has expertise in endocrinology which Dr. Young does not possess.
3. Response (Documentation)
Medicare claims processing manual states that a request for consultation from an
appropriate source and the need for the consultation (i.e. the reason for the consultation) shall be documented in both the consulting physician/NPP’s and the requesting
Physicians in a group practice are cautioned not to routinely
report consultation services between physicians and NPP’s within the same group practice
setting.
professional’s plan of care in the patient’s medical record. Therefore, Dr. Wright must prepare a response and send it to Dr. Young, advising of his/her opinion and findings. In a shared medical record (e.g. group medical practice or hospital setting) the
requesting professional can also write a consultation request on a physician order form and place it in the patient’s chart.
Even though it is not a requirement, providers can also contribute to proper
documentation by submitting a letter, (i.e. in an office setting), or written report, (i.e. in a large multi-specialty group) back to the requesting physician thanking the requesting provider for “asking me to see John Smith in consultation for management of his diabetes mellitus.” The physician/NPP should then proceed to state his/her opinion or advice to the requesting physician. This will put the appropriate language in the
requesting professional’s chart in the event that he/she has not done so. As a
consultant, the provider can be held responsible only for what is required for his or her own record.
In a practice where the medical record is shared, such as a multi-specialty group, the consultant’s report may be included in the medical record, thus not requiring a separate letter.
Additional Consultation
Providers may be requested to perform multiple consultations to the same patient for the same problem at a later date, and such an encounter may be reported with the consultation codes. According to the Medicare Claims Processing Manual, if the physician continues to care for the patient for the original condition following the initial consultation, a repeat consultation service cannot be reported during the ongoing management of this condition.
An example would be when Dr. Young requests a consultation from Dr. Wright. Dr. Wright submits his recommendation to Dr. Young, who incorporates the advice into the patient plan of care. The patient shows signs of improvement but, six months later, exhibits the same or worsening symptoms. Dr. Young treats the patient in accordance with Dr. Wright’s earlier recommendation but the patient does not improve. Dr. Young winds up requesting another consultation from Dr. Wright for the same problem. Dr. Wright will again see the patient and make further recommendations to Dr. Young. This second encounter with Dr. Wright can be reported as a consultation.
However, if Dr.Young determines that the patient will benefit more by continuing to see Dr. Wright and refers the patient to Dr. Wright at either of these visits, this is considered a ‘transfer of care’ and Dr. Wright will report the encounter with the appropriate new or established level of service (99201 – 99205) and not as a consultation, even though he periodically may send reports to Dr. Young to update him/her of the patient progress.
It is not mandatory to send subsequent reports to the
requesting physician or appropriate source after every encounter but it is certainly good business
etiquette to keep the requesting professional updated on the patient care
and progress.
Medicare Claims Processing Manual states that, in cases where patients are admitted to a facility setting, a consulting physician such as Dr. Wright can report only one initial consultation code. However, if Dr. Young as the requesting physician assumes that Dr. Wright will take over the care of the patient in the event that an admission is warranted, Dr. Wright cannot report this encounter as a consultation. Rather, he must report it using the appropriate level of new
inpatient care codes (99221-99223).
If the patient and/or family request a second opinion, it may be appropriate to arrange this through the attending physician in order for the initial consultation criteria to be met and reported. Physicians are not required to send a written report to the attending physician if the second opinion was requested by the patient and/or family member, Medicare says.
Initiating Treatment during a Consultation
Very often, physicians or NPPs will meet the criteria for a consultation, but they may also initiate treatment and even continue to provide the patient further services for the condition for which the consult was requested.
It is appropriate for the physician or qualified NPP to initiate diagnostic services and treatment at the initial consultation or a subsequent visit. However, if the intent of the requesting professional was to initiate a consultation – not a transfer of care – the initial visit is a consultation and can be billed as such. Any subsequent E/M services following the consultation shall be reported as subsequent visits for the appropriate place and level of service.
If the initial intent to send the patient was that Dr. Wright will treat the problem (transfer of care), this service must be billed with the appropriate level of service as either new or established E/M.
Transfer of Care
According to the Medicare Claims Processing Manual, “A transfer of care occurs when a physician or appropriate source requests that the consulting physician take over the
responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that particular condition.” When this transfer of care is arranged, the requesting professional is not asking for an opinion or advice to personally treat or continue treating the patient for the condition.
The consulting physician may take over the care of a particular condition, i.e., diabetes mellitus, but not the total care of the patient.
However, in the event there is a transfer of care, the consulting physician or qualified NPP will document this transfer of care in the patient’s medical record or plan of care and report this with the appropriate new or established level of service performed and NOT the consultation service.
Consultation based on time
Sometimes providers may spend more than the customarily allotted time in consultation with a patient. In such cases, the encounter may be appropriately reported based on time, as long as the service is documented and medically necessary. Documentation of a consultation based on time should include, among other things, the physician/NPP’s illustration of who requested the consultation and why, history, physical and decision-making done during the encounter, and most importantly, the total time spent face-to-face with the patient. Providers should note that at least 50% of the total face-to-face time of the encounter was spent discussing the patient’s condition, answering questions, counseling or reviewing results, etc., with the patient. The history, physical, and medical decision-making cannot be used as a basis for the level of service provided based on time.
Since the consultation codes (99241- 99245) are valued greater than any other E/M codes, there is a tendency among healthcare practices to bill these
codes as often as possible. Medicare has reported a great increase in the number of consultation codes reported over the past several years, as well as in the level of consultation visits. To ensure complete compliance for the use of the consultation codes, Medicare is constantly scrutinizing the utilization of these codes. Physicians/NPPs can avoid being
non-compliant by ensuring that all the necessary reporting and documentation requirements are met when reporting the appropriate consultation codes.
Conducting regular audits of your practice’s consultation and new patient billing accuracy will help to assure complete compliance with the guidelines. Physicians/NPPs must be sure to close the documentation loop by reporting back to the requesting professional, so that the
consultation billing is appropriately substantiated. Define a protocol that helps establish when it is appropriate to bill for a consultation. This protocol can include a verification mechanism for determining the requesting professional’s intent for the visit. Is this a transfer of care or a consultation? Do not forget to send the letter/report back to the requesting professional. Audits can be done internally or an external auditor can be hired for the task and the results tracked and filed.
For additional text in the Medicare Manual that addresses the consultation requirements, see CMS Transmittal 788, dated December 20, 2005, which can be accessed at the following link:http://www.cms.hhs.gov/transmittals/downloads/R788CP.pdf.
More information and articles on consultation can be found at
http://www.cms.hhs.gov/MedlearnMattersArticles/
.
Resources: Centers for Medicare & Medicaid Services, Physicians Practice, Medical Economics, cpt Assistant
This is an updated and modified version of an article which was originally published in Executive Decisions in Dermatology, July/August 2008.
The Office of Inspector General (OIG) has had these
codes tagged for regular monitoring in its work plan
for several years.
