RRR Rule in Coding Consultations:
Evaluation and management (E/M) codes are among the major categories of codes that are frequently examined by third-party insurance auditors. Medicare auditors recently have seen many cases in which documentation guidelines are not followed adequately to support a consultation code.Know More At: Medical Coding Training
The key reason the documentation is scrutinized is that the reimbursements for consultations are higher than the reimbursement levels for office visits of similar documentation levels. In most instances, if the guidelines were not accurately followed, the consultation was either down coded or denied. In either case, money is taken back from the practice or the physician.
The office/outpatient consultation codes, 99241-99245, and the inpatient consultation codes, 99251-99255, may be used for either a new patient or an established patient. The inpatient consultation codes may also be used for places of service, such as nursing homes or a rehabilitation facility.
When physicians code a consultation, they should follow the three Rs:
Request:
The consulting physician should receive a written request, including the reason for the consultation, from an appropriate source. Be sure it is documented properly and placed in the patient's medical record, as well as in the requesting physician's plan of care. If the physician is documenting in the chart by hand, the notes must be legible. If the notes are not legible, the visit will be treated as though there was no documentation and the visit did not happen, or the physicians will have their money taken back because the visit should not have been paid.
Before the consultation visit takes place, remember to follow this dual documentation process: The requesting physician, as well as the consulting physician, should enclose the request and the reason for the consultation and document it in each of their charts.
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Render an opinion or advice:
Here are the criteria for rendering care:
• The medical record needs to contain documentation of the consultant’s opinion, advice and (if applicable) any services that may have been ordered or performed. CPT guidelines state that a consultant can initiate diagnostic and/or therapeutic services to help formulate an opinion. CPT instructs that only one initial inpatient consultation should be billed per hospital admission.
• If the transfer of care will be given to the consultant to treat the problem after an opinion is rendered, each visit after the consult should be reported as a subsequent hospital visit (CPT 99231-99233). If not, care remains with the referring physician for treatment and follow-up.
• If the consultant can’t complete an opinion on the initial consult day, or if the referring physician requests the consultant to return later to provide additional advice, use follow-up inpatient consultation codes (99261-99263). You must thoroughly document additional consult days. Also, make sure you describe modifications to management options or advise on a new plan for patient care.
Report:
If the consulting physician does not share the patient's medical record with the requesting physician, then a letter must be sent to the requesting provider. In the case that the consulting physician does share the patient's medical record with the requesting provider, the report should be put on a shared record. The report should always include a thank-you letter for the consultation request and state exactly what the consultant's opinion is concerning the patient's medical problem.
