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E/M question

James Posted Mon 01st of April, 2013 19:06:10 PM

My doctor is a specialist, can we bill 99241-99245 (except for Medicare)for all patients that are referred to us? Instead of 99201-99205 or 99211-99215 for every visit?

SuperCoder Answered Tue 02nd of April, 2013 05:52:27 AM

From Coding Institute article :

If a visit meets the three-R test, it matches the definition for a consultation and you can get paid for it even if the physicians belong to the same practice.

Billing for consultations (CPT 99241 -99245, outpatient; 99251-99263, inpatient) can be tricky, but billing for intra-office consults when one doctor asks for an opinion from another doctor within the same practice may be even more perplexing. But as long as the evaluation meets all of the requirements of a consultation, practices can charge for a consult, even if the two doctors work in the same office.

The best rule to use when deciding whether to report a consultation code is the three-R concept, says LuAnn Langel, CPC, who bills for five physicians and four nonphysician practitioners as coding manager at Medical Associates, PC, a multispecialty group in LeMars, Iowa. To report a consultation, you need a request for an opinion, a review (exam) of the patient, and a written report to the requesting physician stating the opinion of the consulting physician.

Even if the two physicians work in the same practice, the consult rules are the same, says Langel. For instance, if an orthopedist in a multispecialty group requests the written opinion of a physiatrist in the same office to determine whether a patient has multiple sclerosis (340), the practice can bill a consult. The consult is distinguished from a regular office visit because the requesting physician is seeking an opinion or advice regarding evaluation and management (E/M) of a specific problem, says Langel. Although a written request for a consult is not required, the request should be documented in the patients medical record, and a written report must be furnished to the requesting physician.

Why Staff Consultations Are Different

Section 15506 of the Medicare Carriers Manual (MCM) states, Medicare will pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice, as long as all of the requirements for use of the CPT consultation codes are met. Billers should be aware, however, that some practices standard staff consultations may not meet the requirements of a consult.

What Medicare and some other payers wont pay for is whats called a staff consultation, says Cindy Parman, CPC, CPC-H, principal and managing partner of Coding Strategies Inc., a coding and billing firm in Dallas, Ga. A staff consultation is when a practice that has several different specialists in the same practice holds regularly scheduled staff consultation time to discuss their patients and to determine whether anything is inter-related. For example, says Parman, if Im managing an orthopedic patient, I might say to my physiatry partner, I think theres a problem with this patients wrist and you should see her to determine whether theres any kind of nerve disorder. But talking about a patient like this in a group setting and sending the patient to ones partner for a visit is different than a formal request for an opinion or advice.

Parman says that this example could be billed as a follow-up E/M service (99212-99215). Medicare says that the request for a consultation has to be documented. You can document a verbal conversation, but its not as easy to prove it was a consultation when it comes time to do the auditing. What I would recommend, if theyre all working together and managing the patients as a group, is that they dont charge for a consultation unless their documentation is really perfect.

Parman says that doctors who bill intra-office consults should be sure the written report is sent back to the requesting physician. The report should start with something like, Thank you for the opportunity to examine your patient and provide my opinion, and in my opinion this patient needs to have carpal tunnel release at the same time youre going to repair her wrist fracture.

Standing Orders for Consults Not Covered

The MCM states that Medicare will not cover standing orders in the medical record for consultations. For example, some hospitals will say that every patient being treated by a physiatrist for fibromyalgia (729.1) has to be seen by a rheumatologist as well. But just because the hospital requires it doesnt mean Medicare will pay for it, says Parman. They also wont pay for consults in practices where one doctor likes to get his partners opinion on every patient he sees. There has to be a specific reason theyre seeking an opinion from another doctor, whether theyre in the same group or the same specialty.

Many billers are concerned that their intra-office consult claims will be denied because the practice is reporting the consult under the same name and practice identification number. The patients insurance should not deny the claim just because the two physicians work in the same office, says Langel. Even if theyre both physiatrists, the consult can be paid, as long as the same three- R rules apply.

If a physiatrist who specialized in muscle pain evaluated a carpal tunnel (354.0) patient who suddenly lost use of her finger (354.9), he could ask his partner, a physiatrist specializing in paralysis, for an opinion on what caused the paralysis. In this case, because both doctors are physiatrists, says Parman, you might have to submit a paper claim along with a letter explaining that the two physiatrists practice in different specialties, which necessitated the consult. And remember to have proof of the request for opinion and the report of findings to back up your claim, says Parman.

Transfer of Care

If, after the consulting physiatrist examines the patient, a decision is made to transfer care from the requesting physician to the consulting physiatrist, the consult codes no longer apply. The MCM states, A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance ... Physician consultants may initiate diagnostic and/or therapeutic services at the same or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patients condition should be reported as established patient office visit or subsequent hospital care, depending on the setting.

Patient-requested second opinions do not count as consults. A consultation has to be physician-initiated, says Parman. If the patient requests a second opinion, the second-opinion providers office would bill a new patient visit or a confirmatory consultation [99271-99275].

Although Medicares rules on consultations are clearly stated in the MCM, commercial carriers may have their own regulations about paying for consults. Billers should check their insurance contracts to determine the specific rules on billing for consultations.

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