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Orthopedic Coding Alert

'Consult Plus'? Turn to These Examples for Coding Success

Watch the global period to help clue you in to the proper modifier Mastering consult coding guidelines is hard enough. Applying them in the real world of orthopedics -- when the orthopedic surgeon initiates diagnostic and therapeutic services, too -- can give you a world-class headache. Shore up your consult coding confidence with these expert insights into when you can code a consult. Get the Consult/Treatment Rules Down Pat "Consultation services have always been a -hot- topic as there are many interpretations of what constitutes a consult," says Quita W. Edwards, CCS-P, CPC-Ortho, CPC-I, with C.A.S.E. Contracting Services in Fort Valley, Ga. CPT and CMS have "a wealth of information available to assist in the decision-making process," she adds. CPT rule: "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit," state CPT's consultation guidelines. CMS rule: "A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit," according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.B. Medicare will pay for a consult unless a transfer of care occurs, meaning a qualified provider asks the surgeon to "take over the responsibility for managing the patients- complete care for the condition and does not expect to continue treating or caring for the patient for that condition." If a transfer of care occurs, you should report a new or established patient visit rather than a consult (99241-99255) ( Consult tip: Before you can decide whether to report a consult on the same date as diagnostic or therapeutic services, you must determine whether the surgeon provided a consult. See "Don't Code Another Consult Until You Learn These Rules" on page 121 for more information on consult requirements. Consider Consult for MRI + PT Recommendation One key element of consult coding is documentation showing a qualified provider asked your surgeon for advice and did not transfer care, so you should be on alert for these situations. You shouldn't assume certain situations always result in a consult, but you should consider whether your surgeon's documentation supports coding a consult with other services when a physician requests your surgeon see a patient with an orthopedic problem that ends up not requiring an orthopedic surgeon's expertise for treatment, says Leslie Follebout, CPC-Ortho, PCS, coding department supervisor at Peninsula Orthopaedic Associates in Salisbury, Md., and senior orthopedic coder and auditor for The Coding Network. Example: Follebout offers this scenario: A school-age child who sprained her ankle during softball season is now having recurrent problems during field hockey practice. Her pediatrician requests the orthopedic surgeon's advice on whether she requires surgery at this point, or if not, what the orthopedic surgeon would recommend [...]