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Part 2: Documenting a History
Part 3: Documenting an Exam
Part 4: Documenting Medical Decision Making
Part 5: Documenting Consults
Part 6: Documenting Pre-Operative and Confirmatory Consults
Part 7: Time-Based Codes
Part 8: Linking to Resident Notes
Part 9: Modifiers 24 and 25This education is Part 5 of a 9-part series on documenting and selecting the level of service for outpatient visits.
R R R
The request for a consultation may be made in written or verbal form, but the request for the consultation must be documented in the patient’s medical record.
When all three consult requirements are met (Request, Recommendation, and Report) AND all three E/M Key Components (HX-EX-MDM) are documented AND support the level of consult selected, then the physician may bill a consult code.
The level of the E/M consult service should be selected based upon the three (3) key components performed and documented:
*Medical Decision Making
I would like you to assume all care of my patient
That’s fine. Just have your office send over all records.
Medicare Carriers Manual 15506 states:“ Pay for an initial consultation if all the criteria for a consultation are satisfied. Payment may be made regardless of treatment initiation unless a transfer of care occurs.”
“A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.”
Medicare Carriers Manual 15506 statesIf a“complete transfer of care”occurs,“The receiving physician would report a new or established patient visit depending on the situation and setting (office or inpatient).”
Dr. Gim, an Internal Medicine physician contacts a patient’s OB/GYN physician who agrees to serve as PCP for the patient.Which scenario describes a consult? Which describes a transfer of care?
Consult: total care not transferred
New or established patient: total care of patient transferred in advance
Consult: total care not transferred
CPT does not limit the use of the consultation codes according to whether or not the physician providing the consult service is of a different specialty field than the physician requesting the advice or opinion.Same-Specialty Consultations
CPT coding guidelines do not require that the diagnosis be known or unknown at the time of the request for consultation.
A consultation may be reported regardless of whether the diagnosis is known or unknown, provided the requirements for a consultation are met.Diagnosis Known or Unknown
2004 LA Medicaid Professional Services Training Manual page 23
If, by the end of the consultation, the consulting physician knows or suspects that the patient will have to return for treatment, the appropriate level evaluation and management (E/M) code should be billed rather than the consultation code.LA Medicaid – Consult Guidelines
Consults cannot be billed if the service falls in the Global Surgery Period:
For procedures defined as having global surgery periods there is no opportunity to bill an Evaluation and Management service (visit) the day before or the day of the procedure.
None of the scenarios are LA MEDICAID – use Medicare/Commercial Consult Guidelines in determining whether the situation warrants a consult code.
The primary care physician evaluates an established patient who presents to the ambulatory care facility with a complaint of rectal bleeding. The PCP requests a GI consultation. The consulting GI physician documents a history, exam, and medical decision making, and performs a diagnostic colonoscopy.
A 10-year-old patient presents to the ambulatory pediatrics department with a painful, swollen, right wrist. The pediatrician decides to request an orthopaedic consultation. The orthopaedic physician evaluates the patient in the orthopaedic clinic and then confers with the pediatrician. The pediatrician then transfers definitive care to the orthopaedic physician who applies a splint.
Transfer of care for the ortho problem from the pediatrician to the orthopedist DOES NOT preclude billing of consult.
To qualify as a Transfer of Care, the pediatrician would have had to request in advance and received agreement that the orthopaedist assume total care of the patient.
In this instance, the care for ONLY the orthopaedic problem was transferred.
If the orthopaedist writes a report AND documents all three E/M Key Components (History, Exam and Medical Decision Making), a consult code may be billed, along with the application of the splint.
A 52-year-old male makes an appointment with the urologist after experiencing flank pain and hematuria. The urologist documents a history, exam, and medical decision making and recommends further treatment.
This is a self-referral; not a consult.
Complete and Sign the “Consults Codes” Quiz
Fax to: 504-988-7777