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April 2008

Savvy Coder: Coding & Reimbursement
Confused About the Consult Codes? Here’s How to Avoid Denied Claims
By Sue Vicchrilli, COT, OCS, Academy Coding Executive 

Misuse of the consult codes is a common cause of denied claims. Suppose, for instance, a “consultation” was initiated by a patient and/or the patient’s family but was not requested by a physician or nonphysician practitioner (NPP*). This does not fall within CPT’s definition of a consultation, so an office visit code may be appropriate but not a consult code.

Is it a consultation or a transfer of care? Only the former can be billed with a consult code, so it is important to understand how carriers differentiate between the two types of encounters.

What is a consultation? The CPT defines it as a 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. An appropriate source is typically defined as someone with a National Provider Identifier (NPI) number.

What is a transfer of care? In January 2006, CMS updated its guidelines in an attempt to clarify the difference between consults and transfers of care: “The transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition. When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition.”


When Using the Consult Codes

Document the request. The request to provide an opinion or advice must be documented in the medical record. This request may arrive in a variety of ways. It could be a phone call from the referring source. It could be written on a prescription pad. If physicians regularly receive requests to provide consultations, they can provide their referring sources with forms for making those requests. In some cases, the patient may verbally inform you of the referring source’s request, in which case it might be wise to call that source to confirm the request.

Fill out CMS form 1500 correctly. The referring source’s name and NPI number should be listed in boxes 17 and 17A, respectively.

Document the response. The physician-consultant must send a letter detailing any findings and recommendations back to the referring source. For intraoffice consultations it is not enough to have the requesting source read a copy of the encounter and sign-off, though a summary note to that person may suffice.

You can initiate care. A physician-consultant may initiate diagnostic and/or therapeutic services at the same visit or at a subsequent visit.

Beware the standing order. There must be a specific request for a consult.

* Medicare defines NPP as “any nonphysician licensed medical professional” and includes in its definition providers such as physician assistants, nurse practitioners and clinical nurse specialists, as well as social workers, physical therapists and speech therapists.