Developing an E&M Chart Review Process. Presented by: Gary Cavett, CPA President Find out more at www.gmcavett.com. Audit vs. Review. Audit. Provides a reasonable basis for expressing an opinion Detailed, independent testing procedures Verification and substantiation procedures
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Gary Cavett, CPA
Find out more at www.gmcavett.com
“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 a physician or other appropriate source.” [CPT, 2004]
“Specifically, a consultation is distinguished from a visit because it 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 [Medicare Carriers Manual, §15506 (A)(1)]
Even if a patient has previously been charged for a consultation relative to a condition, that same patient can be charged a consultation again for the same condition if a request for another consultation is made by the attending physician.
Consultation - An E&M service provided by a physician whose opinion or advice of a specific problem is requested by another physician or other appropriate source.
1. Consult vs. Visit: The consultant prepares a report of his/her findings, provided to the referring physician, for the referring physician’s use in treating the patient. A consultant may initiate diagnostic and/or therapeutic services. However, when the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally, the receiving physician may not bill a consult. (If the referring physician tells you to take over and manage the care of the patient, you cannot bill a consult).
2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record. This can be either verbal or written. But, either way, it should be documented in the patient's medical record by the requesting and the consulting physician.
3. After the consultation is provided, the consultant prepares a written report of their findings, which is provided to the referring physician. This report cannot be verbal. Copies of progress notes also cannot be used as the sole written report.
4. Consult Followed by Treatment: If the referring physician does not transfer the responsibility of patient care to the receiving physician until after the consult service is completed, the receiving physician can bill a consult. After the consulting physician assumes responsibility for the patient care, subsequent visits should be reported as established patient visits or subsequent hospital care, depending on the setting. (This means that a physician can treat and consult on the same day, as long as they get back to the initial doctor before the treatment begins.)
5. Consult Requested by Member of Same Group Practice: Consultations may be requested within the same physician group practice. This may be done as long as all the requirements are met for use of the CPT consultation codes.
6. Documentation for Consult: The request for a consult from the attending and the need for a consult must be documented in the patient medical record. The consulting physician must provide a written report to the requesting physician for his/her use in treatment. In an inpatient setting, the request may be documented as part of a plan written in the requesting physician’s progress note, an order in a hospital record, or a specific written request for the consult. In an office setting, the requirement can be met by a specific reference to the request.
7. Consult for Preoperative Clearance: You can bill a consult for preoperative clearance for a new or established patient when the consult is done at the request of a surgeon.
8. Post-Op Care by Physician who did Preoperative Clearance Consult: After a physician completes a pre-op consult in the office or hospital, the physician should not bill another consult if he/she then assumes responsibility for the management portion or all of the patient’s condition(s) during the post-op period. In an in-patient setting, the physician who performed a pre-op consult and assumes responsibility of the management of a portion or all of the patient’s condition(s) during the post-op period should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she provides. In the office setting, physicians should use the appropriate established patient visit code during the post-op period. A primary care physician or specialist who performs a post-op evaluation of a new or established patient at the request of the surgeon may bill a consult for E&M services furnished during the post-op period following surgery as long as the physician did not already perform a pre-op consult. (This clarification, in June of 1996, states point-blank that a non-specialist can bill consults for pre-op care.)
9. Surgeon Requests Another Physician Participate in Post-Op Care: If the surgeon asks a physician who has not seen the patient for a pre-operative consult to take responsibility for the management of an aspect of the patient's condition during the post-op period, the physician may not bill a consult because the surgeon is not asking that physician's opinion or advice for the surgeon’s use in treating the patient. The physician’s service would constitute concurrent care and should be billed using the appropriate visit code.
The actual issue that has to be answered is whether there is a transfer of care. If the complete care of the patient’s problem has been turned over to the specialist and that specialist agrees to accept accountability for the patient’s care prior to an initial evaluation being performed then a consultation code cannot be billed.
Request:Can be written or verbal and also must be documented in the patient’s medical record. [MCM § 15506 (A)(2) and (D) and CPT Assistant November 1999]
• Don’t assume the request is acknowledged in the requesting physician’s medical record.
• “Who may we thank for referring you?” on the patient demographics sheet should not be used as proof that a consultation was requested. Ask the patient if another physician has recommended the evaluation.
• Just because the patient has a managed care referral/authorization form does not mean it is a consultation request.
Rendering: The need for the consult, and also the history, exam and medical decision making components of the evaluation has to be documented in the patients medical record.
Report: The requesting physician must be furnished with a written report. [MCM § 15506 (D). “…communicate findings and/or recommendations by written report to the requesting physician or other appropriate source.” [CPT Assistant, August 2001]
*Documentation must be textbook perfect*
If the patient only wants a recommendation for someone their doctor trusts for services that this patient will be needing on their own in the future then the doctor providing this information is not asking for advice or opinion and this service is not considered a consultation.
*Note: The above is a requirement for Medicare only. CPT has not specified any rules regarding post-op consultations when pre-op clearance was performed by the same physician/group.
Office or Outpatient (99241-99245)
*Medicare Carrier’s Manual, §15506 (A)(1)
“CPT guidelines do not set restrictions regarding individuals who may be considered an ‘appropriate source’…..Some common examples include a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language therapist, psychologist, social worker, lawyer or insurance company…” [CPT Assistant, September 2002]
“Any procedure or service in any section of this book (CPT 2004) may be used to designate the services rendered by any qualified physician or other qualified healthcare professional.” [Introduction, CPT 2004 Professional Edition, page xiii]
Primary Care Physicians:
-PCP needs to evaluate the patient before surgery. The surgeon’s request to have this evaluation done is documented in the patient’s medical record.
-A medically necessary evaluation is provided by the PCP.
-A written report from the PCP showing the results of the evaluation and recommendation for surgery is given to the surgeon.
“Non-physician practitioners, e.g., nurse practitioners, certified nurse mid-wives or physician assistants, may….also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of non-physician practitioner in the State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules.” [MCM §15506 (C)]
[CPT Assistant, January 2002, “Beyond the Ordinary: Coding ‘Challenging’ E/M Circumstances,” Case #2 – “The fact that this is an established patient of the family practitioner is irrelevant.”] Medicare agrees [MCM § 15506 (E) and (F)].
[CPT Assistant, June 1999 and April 2000]
[CPT Assistant, April 2000]
* If there are diagnostic or therapeutic services that were performed on the same day as the consultation evaluation.
*Should be used when the evaluation is required by a third party payer.
-57“Decision for Surgery”
* Most often used for emergency room and inpatient consultations.
* Use if the decision to immediately perform surgery was a result of the consultation evaluation.