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 May 2009 Issue

Outpatient Consultations 101

(NOTE: You can also read the footnoted version of this article.)

Do you think you have heard the last word on consultations? Think again!  The definition and criteria for coding consultation services is bringing great concern to practices.

Let’s start with a “truth in coding” quiz!

  • Have you shied away from reporting consultation services because you heard consultation codes are under scrutiny?
  • Do you report all or most new patients as consultations because you are a hand surgeon?
  • Do you know if the percentage of consultation codes you report varies from your partners? How about state or national data for hand surgeons?  How do you know? 

What is a consultation service and why all the fuss?

Step 1: Know the official definitions:

CPT says:
 “A consultation is a type of service 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”

Without a documented request for the hand surgeon to give an opinion or advice regarding a specific problem, don’t use a consultation code. 

What Does Medicare Say?
Medicare says, “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.” 

Medicare puts some specifics into their definition and further defines the consultation, but does not shy away from the fact that another provider is asking the hand surgeon for “advice, opinion, recommendation, suggestion, direction or counsel” in evaluating or treating…”

  • Does a documented request exist? If yes, you have the beginning for using a consultation service code as the request for consultation is the first step. Absent a request, report a new or established patient visit.
  • Note Medicare clearly indicates the request for consultation can be for the purpose of “evaluation or treating”, which means that “just because the diagnosis is known does not negate a consultation.”
  • If there isn’t a consultation request or if the patient “self refers” or if the other provider sends the patient for treatment without a request for an opinion regarding the disease process or how to evaluate it, you should report the appropriate new or established patient visit as there is no request for consultation.

Step 2: Written or Verbal Request?

CPT states:
The request for consultation can be a verbal or written request.

Medicare says:
 “A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.

The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.”

We can hear you now asking yourself:
“Do I really have to validate that the physician who sent the patient has requested the consultation in his/her plan of care? I can hardly keep up with the documentation requirements for my own work!”

The Physician Regulatory Issues Team (PRIT) addressed this in a statement related to the documentation of the request in the requesting physicians note.  “In December of 2005 Transmittal 788 seemed to impose the additional requirement that the consulting physician verify that a written request for a consultation has been made in the patient chart before billing for the consultation. The MGMA has asked that this requirement be reconsidered. The PRIT is discussing the issue with appropriate staff. April 12, 2006:  Medicare does not expect the consulting physician to verify that the requesting physician has documented the consultation request in his/her patient's medical record.”

Develop an internal protocol with the appointment scheduling team to accurately identify the reason for the appointment, who requested the visit and the reason for the visit. Work with the patient and referring physician practice to obtain a written request for the consultation including the reason.   Create a “request for consultation form” and send to your key “referring” physicians/providers or post the form on your website. This will facilitate the physician/provider requesting your consultation to document the request for consultation and provide background information on the reason for the request.  A faxed form or downloadable form on your website makes it less disruptive to both practices and allows the form to be transmitted electronically. 

If you have the request for consultation and you document the request, you are on your way to a consultation.  When all the documentation is present, document the chief complaint along the lines of, “Patient is seen at the request of Dr. Rheumatology for evaluation of her arthritic wrist and failure to respond to conservative measures.” 

Step 3: Diagnostic Testing and/or Treatment

If the hand surgeon orders diagnostic tests and/or initiates treatment can a consultation service be reported?   Yes, if all requirement of a consultation are met, the ordering of diagnostic testing or initiating treatment does not negate a consultation.  Read on!

CPT says:
“A physician consultant my initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

Medicare says:
“A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit.”

1) Another provider/physician has requested the Hand Surgeon for an opinion or advice regarding a specific problem and
2) The request (verbal/written) for consultation is documented in the medical record.
3) The hand surgeon orders a wrist x-ray and gives an injection
The case is building for a consultation service, continue identifying building blocks for the consultation service.  If you do not have the request for consultation, then this is not a consultation service regardless of diagnostic testing and/or treatment initiation.

Step 4: The Report!

The consultation request is in hand, you perform the service, but you do not send a separate report—have you lost the ability to report a consultation service?  Most likely yes, but there are a few caveats according to Medicare.

CPT says:
The consultant’s opinion must be “communicated by written report to the requesting physician or other appropriate source.”   CPT describes a “written report” as a work product, thus the report must be separate from the E&M note.

Medicare says:
In the instance of a shared record, i.e. inpatient setting, Emergency room or instances where the requesting and consulting physician share the same medical record a separate report is not required. But, in all other settings a separate written report to the requesting physician is required.

So now, the litmus test exists:  You have met the requirement to report an outpatient consultation service (99241-99245) if you have:
1) A verbal or written request for consultation to give your opinion or advice
2) Documented the request for consultation
3) Possibly ordered diagnostic tests and/or initiated treatment
4) Sent a separate written report with the Medicare exceptions noted.


1. Scenario: 
Dr. PCP calls the office requesting Dr. Hand evaluate the patient for right wrist pain. All other requirements above are met: 

Report:  Outpatient Consultation Services

2. Scenario:
Patient calls your office because her friend (a physician) said she was very happy with the outcome of her carpal tunnel surgery.

Report: New or established patient visit. While the friend is a physician, the physician is not asking for your opinion, they are merely acting as a referral source. Send her a note, thanking her for referral (assuming HIPAA compliance of course!)

3. Scenario:
Patient is seen by Dr. Hand in the ER at the request of Dr. Emergency for evaluation of significant wrist pain.  Dr. Hand goes to the ER and evaluates the patient and suspects a torn ligament in the hand/wrist.  Dr. Hand recommends the patient be placed in a static splint and will see the patient in follow up.

Report: Outpatient consultation and ensure the documentation requirements are met.

4. Scenario: 
Same patient as above, however now Dr. Hand is not called to the ER and the ER physician “refers” the patient to Dr. Hand. Dr. Hand sees the patient three days later in the office.

Report:  New or established patient. This is not a consultation as there is no request for consultation.

Okay, I understand, but now, how do I asses my risk, if any?
Key to knowing if you are at risk not only with consultation services but with all levels and categories of E&M services begins with profiling your E&M services.

KarenZupko & Associates, Inc (KZA) recommends the E&M Analyzer as a means to profile your E&M service distribution and identify patterns of risk.  ASSH members receive a discount on the product for a limited time only.

The E&M Analyzer Shows I am an Outlier, Now What?
Outlier or not, but especially if you are, it is essential you audit your E&M categories and levels of services where you differ significantly from either the state data, national data, or if you are in a group practice, your partners.

As a hand surgeon, if you are reporting services to Medicare using the Hand Surgery specialty designation, you profile yourself against other hand surgeons. If you are reporting services using the orthopaedic specialty designation, you will profile yourself using the orthopaedic specialty data. If you are reporting services as using the plastic surgeon designation, you will profile your services using the plastic surgery specialty data and if you are reporting services using the General Surgery designation, you will profile your services using the general surgery data.  If you have questions, KZA can assist you determine which benchmark data best fits your profile!

Don’t delay!  If you are an outlier, you are at risk financially, whether you are over or under coding. The goal is to code accurately, minimize your risk and be paid for the work performed and supported by your documentation. 

Written by Mary LeGrand, RN,MA, CCS-P,CPC and submitted by Karen Zupko and Associates.


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