1. Guidelines for Consultations
Evaluation and Management Coding

2. Why the Concern? Radar Screen for incorrect CPT coding.
In 2000, allowed Medicare charges for consultations totaled $2 billion.
Being audited by CMS and other insurance companies for inappropriate billing.
Date for compliance with revised Medicare Transmittal 788 on Consultation Services was January 17, 2006.

3. Three Key Components (3 R’s)
#1 R is the Request
A request for a consultation from a physician or qualified non physician practitioner and the need (reason) for consultation.

4. Intent of 1st R - Request
Intent of a consultation request is for a physician to ask another physician for:
Advice
Opinion
Recommendation
Suggestion, etc. in evaluation or treating patient because that physician has expertise in a specific medical area beyond the requesting physician’s knowledge.

5. Requirements of 1st R Request must be written in the record.
Reason for consultation must be stated.
In hospital setting, the request and reason should be written by the requestor on the order form in the medical record.
Example: Consult is requested on Ms Smith in Room 220 for unstable angina.

6. Three Key Components (3 R’s)
#2 R is to Render an opinion
After obtaining the order/request for a consultation, the consulting physician:
Renders his/her opinion to the requesting physician;
Makes a decision for treatment option(s);
Performs and/orders a separately, distinctive diagnostic and/or therapeutic procedure(s).
CPT Assistant, September 96, Vol.6 Issue 9

7. Requirements of 2nd R
The rendering of the consultant’s opinion (recommendation, advice, suggestion) must be clearly documented in the office or hospital chart.
Consultation report is dated/timed/signed by the consultant.

8. Three Key Components (3 R’s)
#3 R is to Respond
After the consultation is provided, the consultant shall respond by preparing a written report of his/her findings, which shall be provided to the referring physician.

9. Requirements of 3rd R
In a hospital setting, a consultation report in the shared medical record is sufficient to meet the requirement for “respond”.
In an office setting a separate letter from the consulting physician, in addition to the consultation report, is required.
FYI for physicians in private practice

10. Options of Requestor
After the consultant’s advice/opinion is rendered, the requesting physician has two options:
Request the consultant to assume the care of the patient for the specific problem, or
Elect to manage the patient himself
CPT Assistant, August 2001

11. CPT Coding
If the three key components (request, render, respond) are met, the CPT code for consultation is assigned.
If any one of the three key components is not met, the CPT code for subsequent care is assigned.

12. Examples Not meeting the 3 R’s
Standing orders for consultations
No written order for consultation
Lack of written report of a consultation with the consultant’s opinions, recommendations, advice, etc.
In a clinic setting, lack of a separate letter back to the requesting physician, in addition to the consult report. A cc at the bottom of the consultation report is not sufficient to meet the 3rd R.

13. Evaluation & Management
Reasons an order for “Evaluation and Management” do not meet the 3 R’s:
No request for advice, recommendation, etc. for a specific reason.
No option for requesting physician to elect to manage the patient himself based on the consultant’s recommendations.
Decision already made at the time of the order for another physician to assume the care of the patient or assume the care of a specific problem of the patient.
Considered a transfer of care and coded as a subsequent visit.

14. QUIZ (from Medicare carrier)
If the answer is “no” to any of the following, do not code as consultation:
Did you receive a request for an OPINION from another physician?
Does the record clearly document who made the request and the nature of the opinion (reason) requested?
Have you provided a written report of your opinion/advice to the referring physician?

15. QUIZ….continued
Though the referring physician may have asked you for a “consultation”, can not report as consult if the answer is no to any of the following:
Will your opinion be used by, and in some manner affect, the requesting physician’s own management of the patient?
Will the referring physician be involved in subsequent decision making about the problem for which the consultation has been made?
For pre-op clearance, is the service requested specifically for pre-op clearance that is medically necessary considering the patient’s condition and the procedure planned?

16. Quiz….continued
Never report separately payable services to Medicare for completion of mandatory pre-op or pre-admission H&Ps – when payment for the H&P has been made or will be made as part of the global payment for the surgical period.