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Orthopedic Coding Alert

Guest Columnist:

Jill M. Young, CPC-EDS: Consultations for Orthopedists -- to Bill or Not to Bill? Is That Not the Question?

A breakdown of when you can -- and can't -- bill consults is essential for every office Does your office bill consultations? What about in the hospital? The emergency department? Do you ever bill a consultation on a patient referred to your provider, or do you never bill consultations? Appropriate and compliant consultation billing is a frequent cause of concern for specialists, and orthopedic physicians have their own particular concerns. When to bill consultations (99241-99255) has been a question/problem that plagues offices everywhere. Many practices have decided not to bill consultations ever. Sometimes the decision is made based on place of service, and sometimes it is based on the diagnosis. Sometimes it is an arbitrary decision that is made across the board. Personal experience: I have worked with orthopedic offices that have decided to never bill consultations. Their fear of failing in an audit is so great that they just stop considering a consult code when providing services to patients. In doing so, they may be sacrificing income for themselves and their practices for services provided that meet the consultation criteria. By being close-minded about it, they are losing money.
Doesn't Have to Be All or Nothing I see the question of consultation coding as a particularly complicated choice for orthopedic practices, but the decision should not be made as an -all or nothing.- For patients whom orthopedists see, there are many instances when a consultation code is the correct service to bill because it is the service rendered and, hopefully, documented. You should examine several factors, including the consult request, and then decide whether a consultation is the most appropriate code to use. CPT states, -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.- Additionally, it states, -A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.- Ask these questions: Remembering CPT's definition, when was the last time your physician was asked for his opinion and advice on a new osteoarthritis patient? Have there been occasions when your orthopedist started a patient on a therapy, and she returned to her requesting physician for continued care? Would those instances constitute a consultation or just a new patient visit? What did the documentation show? What would an auditor think? Did you make the correct coding choice?

What You Need to Qualify If appropriately requested and documented, this visit can qualify as a consultation if your orthopedist meets the -Three R-s- of a consultation (referral from a healthcare provider, review, and report back to the referring party). Certainly, your physician would be rendering his [...]

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