Podcast Episode 3: Office Consultation Coding
Episode Summary: Office consultation coding requires three documentation items in addition to fulfilling the standard evaluation and management services documentation of history and physical exam. These three items are: Request, Reason, and Report. The requesting physician must document a request to the consulting physician. There must be a reason for the consultation. And, the consultant must send a report of the consultation back to the requesting physician. If these three criteria are not satisfied or there is a transfer of care, a consultation billing code cannot be billed. Hosts Neal Sheth and Dr. Piyush Sheth explore these requirements in detail and resolve scenarios that highlight grey areas. Of special note is that Medicare no longer recognizes consultation codes.
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Hosts: Neal Sheth, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC
Welcome to Unraveling Medical Coding. How can the complexities of medical coding be simplified? Can healthcare providers and professional medical coders maintain efficiency in an environment of ever-increasing complexity? These are the issues we discuss in each episode of this podcast.
This episode’s topic deals with Office Consultation Coding.
NEAL SHETH: On the last episode we talked about the new Office Outpatient Coding guidelines that went into effect January 1, 2021. However, it's important to note that these guidelines don't apply to Office Consultation coding. So, I want to pick it up there. Can you give us some background into Consultation coding and why we would want to bill consultations?
PIYUSH SHETH: Consultation coding can be applied to services rendered in the office or in a hospital setting. There are three requirements that must be met to code for a consultation in addition to the general requirements for documenting history, physical exam, and medical decision making. This makes documentation more tedious, but the reward is higher reimbursement. Unfortunately, as of January 1, 2010, Medicare eliminated payment for office consultation CPT codes 99241 to 99245 and hospital consultation CPT codes 99251 to 99255 and some health insurance companies have followed suit. Nonetheless, there are still many health insurance companies that allow for consultation coding and billing.
NEAL: What are those three additional requirements?
PIYUSH: Let’s first define a ‘consultation’. A consultation is a request for advice or opinion regarding evaluation or management of a specific problem.
This is different than a ‘transfer of care’. A transfer of care occurs when a physician requests that another physician take over the responsibility for managing the patient’s condition. An example of this is when a patient is referred to you from the ER.
For consultations, the three additional requirements are Request, Reason, and Report.
The first requirement is that there must be a request for consultation. A verbal request alone does not meet this requirement. Consultations may be requested by physicians, physician assistants, nurse practitioners, chiropractors, physical therapists, psychologists, social workers, lawyers or insurance carriers. They cannot be requested by the patient or family members. Documentation must include how the consultant was contacted (e.g., phone, fax, or letter). Likewise, the consultant should document that a consultation was requested, by whom and why.
Secondly, there must be a reason for the consultation.
And lastly, there must be a report of the consultation service, findings, and recommendations. A thank you note to the referring physician for referring the patient to you, or a courtesy copy of the history and physical does not meet this criterion. Rather, the report should be a summary of your evaluation and should provide instruction to the requesting physician to allow them to continue treating the patient.
NEAL: That doesn’t seem too complicated, and therein lies the trap. It can actually be quite difficult to make sure that you are fulfilling all of the requirements and documenting appropriately. To demonstrate, let’s go over a couple of scenarios.
Scenario 1: What if you are consulted twice for a hospitalized patient during the same admission? Can you bill for two consultations?
PIYUSH: No. You are only allowed to bill an inpatient consultation code once per admission. This means that if you are consulted to see a patient and then re-consulted again during the same admission, you cannot bill for 2 consultations, even if the condition you are being consulted for is different.
NEAL: Scenario 2: What about consultations or second opinions mandated by health insurance companies?
PIYUSH: You can bill for those type of consultations by attaching modifier 32 to the CPT consultation code but this only applies to private health insurance carriers that recognize consultation CPT codes. Medicare does not recognize consultation CPT codes, and therefore Medicare also does not recognize the modifier 32.
NEAL: Scenario 3: If a surgeon requests pre-op clearance from the patient’s primary care physician or another specialist such as a cardiologist or pulmonologist, can a consultation be billed?
PIYUSH: Yes. Preoperative clearance consultations are allowed. To clarify the billing, be sure to use an appropriate ICD diagnosis code that indicates the necessity of the consultation (e.g., V72.81 for preoperative cardiovascular exam, V72.82 for a preoperative respiratory exam, V72.83 for another specified preoperative exam or V72.84 for an unspecified preoperative exam). Also use secondary codes that indicate the condition for which surgery is intended and any other diagnoses that arise during the consultation.
NEAL: Scenario 4: How do you bill consultation if you use NP’s or PA’s in your practice?
PIYUSH: What you are asking about are shared/split services. This is when a qualified nonphysician practitioner (NPP) and a physician each provide a portion of the services. Unfortunately, shared/split services cannot be billed as a consultation.
NEAL: Scenario 5: What if a surgeon is consulted to evaluate a skin lesion and he decides to excise the lesion? Since he is providing treatment, is this now considered transfer of care and not a consultation?
PIYUSH: Not at all. Consults can include initiation of treatment as long as the visit meets all three consultation requirements and no transfer of care occurs. For example, in your scenario, if the consultant initiates treatment at the time of the consult, he can add a statement like, “I performed an excisional biopsy while the patient was here for consultation, and the pathology report is pending.”
As another example, let’s say a patient visits his primary care physician with chest pain. The primary care physician requests a consultation from a cardiologist to evaluate the patient and to provide treatment recommendations. The cardiologist evaluates the patient in the office and performs a diagnostic heart catheterization, which shows minimal disease, writes a prescription for the patient, and prepares a letter with findings and recommendations for ongoing care. Even though the cardiologist initiated the care, the service meets all three consultation requirements and can be billed as a consultation.
NEAL: Scenario 6: How about a situation where you are in a group practice and one of your partners specializes in a particular condition that you do not specialize in. Can you send the patient to your partner for consultation?
PIYUSH: Yes, but this is tricky. Same-specialty or same-practice consultations are allowed when the consulting physician has expertise in a specific medical area beyond the requesting professional’s knowledge. The tricky part is that this internal referral has as significant potential for abuse and it is advisable that consultation services should not be reported on every patient as a routine practice between physicians within a group practice.
NEAL: I can see why consultation coding and billing is not as simple as it may seem. Any parting advice?
PIYUSH: The foundation for documentation and coding for consultations requires that all three requirements are met: Request, Reason, and Report. If your documentation is clear regarding these requirements in addition to the key documentation requirements of a history, exam, and medical decision making, you can bill for the consultation.
NEAL: Thanks for clarifying Office Consultation coding and billing.
PIYUSH: My pleasure.
NEAL: Thank you for joining us for this episode of Unraveling Medical Coding. Don’t forget to subscribe to Unraveling Medical Coding from wherever you get your podcasts.