Coding and Reimbursement
Coding for Consultations
How to tell a consultation from an office visit -- and get paid.
 

BY SUZANNE L. CORCORAN, COE

Ophthalmologists are uniquely qualified to render expert opinions about eye conditions. But in order to get paid promptly for a consultation, it's important to code your claim correctly.

Q: When is it appropriate to use a consultation code? It's appropriate to use this code whenever an attending physician consults with you because he needs additional information from a specialist to better care for his patient. The essential attribute of a consultation is the question-answer interplay between you and the attending physician. He asks you to evaluate a problem and provide an answer to his query.

Q: How should we code for consultations? Medicare recognizes three types of consultations:

• inpatient consultations (9925x, 9926x), which involve patients who've been admitted to a facility such as a hospital or nursing home
• outpatient consultations (9924x), which usually take place in your office, although they may occur in locations such as a hospital outpatient department
• confirmatory (or second opinion) consultations (9927x). These are re-quested by the patient, the patient's family, or (occasionally) an insurance company, rather than another doctor.

Q: Is any special documentation required? It's critical that your documentation answer these questions:

• Who referred the patient?
• What is the problem?
• Why was the consultation needed?

The beginning of the patient's medical record should address these questions, and your response to the referring doctor should start by answering them.

Consultations use E/M coding, so you need to supply the same levels of documentation to support the various levels of service as you would when using new patient E/M codes.

In addition, to support a claim for a consultation, documentation must demonstrate that all of the following conditions were met:

Someone requested your advice or opinion. The request, whether verbal or written, may have come from another physician, some other appropriate source, such as a nurse practitioner, or the patient (in confirmatory consultations). The medical record must contain documentation of the request, as well as the need for the consultation.

You performed a history and examination. Diagnostic tests may be ordered separately.

A written report was filed. The report must contain your findings and recommendations. It must be sent to the referring physician to become part of the patient's permanent medical record, and a copy must be kept in your files.

The attending physician did not transfer care of the patient to you. 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 acceptance of care in advance.

Q: Who can request a consultation? The requesting doctor is usually the patient's attending physician, although internists, pediatricians, optometrists, and others would qualify. Generally, an emergency room doctor won't request a consultation; he or she wants to transfer the care of the patient to the ophthalmologist and doesn't expect to have the patient returned for ongoing care.

Q: What about treatment or tests? The initial visit may qualify as a consultation, even if you plan or initiate diagnostic and/or therapeutic services, including surgery. Doing so is simply viewed as a courtesy to the attending physician to expedite patient care.

However, if you see the patient again to provide additional patient care, the patient has become part of your practice; you're no longer acting as a consultant. Those later services should be billed using established patient office visit or subsequent hospital care codes.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or via e-mail at scorcoran@corcoranccg.com.