coding q & a
Understanding Consulting Codes
How, when and what to document.

Q  When do you use a consultation code?

Answer: The essential attribute of a consultation is the question-answer interplay between the attending physician and the consultant. When an attending physician requires additional information, she asks a consultant to "evaluate" the problem and to provide an answer.

  How should you code for consultations?

Answer: Choose from the following:

• Inpatient consults for a patient who has been admitted to a facility such as a hospital or nursing home (9925x, 9926x).
• Outpatient consults, which usually take place in your office or sometimes a hospital outpatient department (9924x).
• Confirmatory consults, which a patient, his family or, occasionally, his insurance company requests (9927x).

 What are the documentation requirements?

Answer: Consultations use E/M coding and are subject to the same rules as new patient E/M codes to support the various levels of service. Documentation must include all of the following elements to support a claim for a consult:

A request. Another physician, the patient (in confirmatory consults) or another appropriate source (i.e., nurse practitioner) requests (verbally or in writing) the consultant's advice or opinion. The medical record must contain documentation of the request, as well as the need for the consultation.

A history and exam. You may order diagnostic tests separately.

A written report. This must contain the consultant's findings and recommendations. It's sent to the referring physician to become part of the patient's permanent medical record. The consultant also keeps a copy in his files.

The attending physician doesn't transfer care to the consultant. 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.

It's critical to document the who, what and why of a consultation. Who referred the patient? What's the problem? Why was the consultation needed? The beginning of the patient's medical record should address these issues. Also, the response to the referring doctor answers these questions.

Q  Who can request a consultation?

Answer: The requesting doctor is usually the patient's attending physician. An emergency room doctor won't generally request a consultation; he wants to transfer the patient to the O.D. for ongoing care.

Q  What about treatment or tests?

Answer: The consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit as a courtesy to the attending physician. This service qualifies as a consultation. If, subsequently, the consultant provides additional patient care, the patient has become part of the consultant's practice and the consultant is no longer acting as a consultant. Those later services are billed using established patient office visit or subsequent hospital care codes.

Q  What is normal Medicare use?

Answer: Within an average optometric practice, outpatient consults occur about 1% of the time.

Inpatient and confirmatory consults take place less than 1% of the time. However, the frequency of consultations in a practice vary; subspecialists tend to do them more often.

SUZANNE CORCORAN IS VICE PRESIDENT OF CORCORAN CONSULTING GROUP. REACH HER AT (800) 399-6565 OR AT SCORCORAN@CORCORANCCG.COM.