Coping with Coding has been developed to provide you with educational
articles focusing on common coding questions and issues facing many
Urologists.
Coding Consultations
by Michael A. Ferragamo MD, FACS
In 2001 CMS paid an estimated $3.1 billion for consultations,
a third of which claims were felt to have been paid in error. A
review of over 400 consultative visits by the Office of the Inspector
General (OIG) found that 19% of the claims failed to meet all the
criteria (see below) for a consultation, 45% were coded at the wrong
level, most over coded, a few under coded, 9% lacked any documentation
at all to bill for a consultation, and 94% of followup consultations
were incorrectly coded.
Because of this 2006 brought some coding changes when billing
for a urological consultation. A consultative service provided by
a urologist or other qualified provide ( physician assistant, nurse
practitioner, clinical social worker, podiatrist, or chiropractor)
whose opinion is sought concerning a diagnosis or treatment option,
must now have a formal written request from the requesting physician
to the consulting physician (urologist) as indicated in transmittal
788 of the Medicare Rules and Regulations.This written request or
form should be in the medical records of both the requesting and
consulting physicians. According to the Claims Processing Manual there
must be a clearly stated direct physician to physician communication,
requesting physician to consulting physician, asking for the consulting
physician's opinion or advice. Needless to say this new requirement
produced much turmoil and concern from most urologists and physicians
both in the private and academic sectors as many saw this request
as impossible to fulfill in this format due to the practices of
the modern day physicians with varying surgical schedules, office
appointments and hours, rounds, etc. However, the Center for Medicare
and Medicaid Services, CMS, understood these concerns, and recently
a CMS source has agreed that the request may be either written as
stated above or may take the form of a verbal request.
If a verbal request is made, this conversation should be documented
clearly in the medical records of both the requesting and consulting
physician. The verbal request can occur between physicians, their
appointment or office staffs, and although not clearly stated, between
the physician and the patient himself. Again documentation in the
medical records of both physicians is of utmost importance. There
should be no doubt in the consultant's mind that this patient encounter
is indeed a consultation request. At times, however, one may wish
to call the requesting physician's office to verify the consultation
request, and this too should be documented in the medical records.
In the consultants written report back to the requesting physician,
I suggest that a statement such as "I am pleased to send
you a report on Mrs. Brown who was recently in my office for a urological
consultation at your kind request" be included and indicating
the true nature of the visit and that the requesting physician did
indeed send the patient for the consultant's opinion. It is also
important to indicate the reason for the consultation and to render
an opinion as requested. Although not a prerequisite, a consultation
verification form may be sent by the consulting physician to the
requesting physician with a request for a return copy to supplement
the verbal communication for the consultation. Recently an article
in the Urology Times, April 1, 2006 stated "In summary, the
rules for consultations have become a little more precise, but have
not changed significantly...Continue to obey the rules, code the
obvious...correctly, and interpret the gray areas to the best of
your abilities, realizing you will not be shot at dawn or lose the
family farm if you're wrong..."
Remember that the four "R's" must
be satisfied for an encounter to be a consultation:
- A request for the consult
- A reason for the consultation - a rendered
opinion or advice
- A written report - back to the requesting party.
- Request for the opinion or advice of the consultant -
probably the most important aspect of coding for consultative services.
For without a request from a physician or other qualified provider,
(NPP), one does not have a consultation.
For 2006 followup consultation codes, 99261 to 99263, used only
in the hospital, were deleted and made invalid. In their place one
should use subsequent hospital visit codes, 99231 to 99233.
Also confirmatory consultations, second /third opinions, codes
99271 to 99275, were deleted for 2006 and are invalid. In their
place use consultation codes 99241-99245 in office or 99251-99255,
in hospital, if a physician asks for a second opinion, or use 99211-99215,
established office visit, or 99201-99205, new patient office visit,
if the patient presents or is sent by his family for a second opinion.
Further questions concerning the above or for any coding questions
or difficulties should be directed to:
Michael A. Ferragamo MD, FASC
Tele: 516-741-0118
E-mail: Liqgold2@AOL..COM
Fax: 516-294-4736 |
