Consultations—Are you billing correctly?

The limitation of ten speed buttons in Epic Ambulatory has sometimes caused confusion with billing the new patient visit codes or a consultation. A "new patient" is a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. If the new patient visit CPT codes are not on your Epic speed buttons, you must go to the Charge Capture screen in the Visit Navigator and click in the "None" hyperlink found in the Additional E/M Codes box o locate CPT codes 99201-99205. Enter the selected code in the box above.

Consultation services require 3 things: (i) a request from an appropriate source; (ii) the consultation evaluation service; and, (iii) a written report. A written request and reason for a consultation must be included in the requesting practitioner’s plan of care. The written request and reason for a consultation must be included in the consulting practitioner’s plan of care. The statement “Thank you for referring” is not enough documentation to support the request. Your documentation should state the request, name of the provider requesting the consultation, and the reason for the consultation.

Examples of appropriate documentation are:

Request: “Mr Jones is seen in consultation at the request of Dr Kane for evaluation for abdominal pain…"

Advice: “Patient sent by Dr. Hoff for my advice about…”

Consult: “Patient seen in consultation at the request of Dr. Kane…”

Evaluation: “Dear Jim, thanks for asking me to evaluate Betsy for…”

In an office or outpatient setting, another consultation may be requested of the same consultant practitioner if the consultant has not been providing ongoing management of the patient for this condition after his/her initial consultation. A transfer of care occurs when a practitioner requests that another practitioner 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. A referring provider does not have to request a consult first. A consultation service may be based on time when the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the practitioner and the patient. Total time spent, counseling time, and the topics discussed must be documented. Payment may be made for a consultation if a practitioner in a group practice requests a consultation from another practitioner in the same group practice when the consulting practitioner has expertise in a specific medical area beyond the requesting professional’s knowledge, and it is documented in the record.

Examples that meet the criteria for consultation:

Example 1: An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. He identifies a questionable skin lesion and asks a dermatologist to evaluate the lesion. The dermatologist examines the patient and decides the lesion is probably malignant and needs to be removed. He removes the lesion which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his code in addition to the procedure code. He codes a consultation code (99241-99245) with Modifier 25 in addition to the procedure code. Modifier 25 is required to identify the consultation service as a significant, separately identifiable E/M service in addition to the procedure code reported for the removal of lesion. The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist.

Example 2: A family practice physician examines a female patient who has been under his care for some time and diagnoses a breast mass. The family practitioner sends the patient to a general surgeon for advice and management of the mass and related patient care. The general surgeon examines the patient and recommends a breast biopsy, which he schedules, and then sends a written report to the requesting physician; the general surgeon codes a consultation (99241-99245). Subsequently, the general surgeon performs the biopsy and arranges to see the patient once a year as follow-up. Subsequent visits provided by the surgeon should be billed as an established patient visit (99212-99215) in the office or other outpatient setting, as appropriate. The family practice physician resumes the general medical care of the patient.

Examples that DO NOT meet the criteria for consultation

EXAMPLE 1: Standing orders in the medical record for consultations

EXAMPLE 2: No order for a consultation

EXAMPLE 3: No written report of a consultation

EXAMPLE 4: The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code.

The Compliance Department has recently created consultation E&M cards as shown below. Please contact Deborah Lyman at (203) 785-3438 or Deborah.Lyman@yale.edu to obtain a card.