Developing an E&M Chart Review Process Presented by: Gary Cavett, CPA President Find out more at

Audit vs. Review

Audit Provides a reasonable basis for expressing an opinion Provides a reasonable basis for expressing an opinion Detailed, independent testing procedures Detailed, independent testing procedures Verification and substantiation procedures Verification and substantiation procedures May include direct correspondence with creditors or debtors to verify details of amounts owed, physical inspection of inventories or investment securities, inspection of minutes and contracts May include direct correspondence with creditors or debtors to verify details of amounts owed, physical inspection of inventories or investment securities, inspection of minutes and contracts Give auditor knowledge and understanding of the entities system of internal control Give auditor knowledge and understanding of the entities system of internal control

Review Does not provide a basis for the expression of an opinion Does not provide a basis for the expression of an opinion Does not contemplate obtaining an understanding of the internal control structure or assess control risk Does not contemplate obtaining an understanding of the internal control structure or assess control risk Requires inquiry and analytical procedures Requires inquiry and analytical procedures Focus on information your company provides that doesn’t validate if the underlying transactions represented by your organization’s financial statements are correct Focus on information your company provides that doesn’t validate if the underlying transactions represented by your organization’s financial statements are correct No source document testing is performed No source document testing is performed Less in scope than an audit Less in scope than an audit Does not require an opinion as to the records like an audit does Does not require an opinion as to the records like an audit does

E&M Utilization

Inter-category Utilization (2007)

E&M Relative Value Units

Consult vs. Referral

Definition of a Consultation “A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by a physician or other appropriate source.” [CPT, 2004] “Specifically, a consultation is distinguished from a visit because it is 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 [Medicare Carriers Manual, §15506 (A)(1)]

Facts about Consultation Services If the diagnosis is known, it can still be considered a consultation. If the diagnosis is known, it can still be considered a consultation. If diagnostic or therapeutic treatment is started by the consulting physician during the initial evaluation it is deemed a consultation. If diagnostic or therapeutic treatment is started by the consulting physician during the initial evaluation it is deemed a consultation. Primary care physicians, nurse practitioners, PAs, clinical nurse specialists and certified nurse midwives can also bill for consultation services. Primary care physicians, nurse practitioners, PAs, clinical nurse specialists and certified nurse midwives can also bill for consultation services. Requesting and consulting physicians do not have to be of different specialties. Requesting and consulting physicians do not have to be of different specialties.

Facts about Consultation Services continued… Even though you’ve seen a patient with a condition and previously charged for a consult, you can bill for a consult again on the same condition when a new request is made for your advice or opinion by the attending provider. Even though you’ve seen a patient with a condition and previously charged for a consult, you can bill for a consult again on the same condition when a new request is made for your advice or opinion by the attending provider. Even if a patient has previously been charged for a consultation relative to a condition, that same patient can be charged a consultation again for the same condition if a request for another consultation is made by the attending physician. Even if a patient has previously been charged for a consultation relative to a condition, that same patient can be charged a consultation again for the same condition if a request for another consultation is made by the attending physician. Inpatient consults need to be billed for evaluation and management services provided in a hospital or similar setting, even when the physician takes over managing an aspect of the patient’s care. Inpatient consults need to be billed for evaluation and management services provided in a hospital or similar setting, even when the physician takes over managing an aspect of the patient’s care. Referral for medical management from a surgeon to another physician is not a consultation. Referral for medical management from a surgeon to another physician is not a consultation.

MEDICARE INSTRUCTION ON BILLING FOR CONSULTATIONS AUGUST, 1999 Consultation - An E&M service provided by a physician whose opinion or advice of a specific problem is requested by another physician or other appropriate source. Codes Consult vs. Visit: The consultant prepares a report of his/her findings, provided to the referring physician, for the referring physician’s use in treating the patient. A consultant may initiate diagnostic and/or therapeutic services. However, when the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally, the receiving physician may not bill a consult. (If the referring physician tells you to take over and manage the care of the patient, you cannot bill a consult). 1. Consult vs. Visit: The consultant prepares a report of his/her findings, provided to the referring physician, for the referring physician’s use in treating the patient. A consultant may initiate diagnostic and/or therapeutic services. However, when the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally, the receiving physician may not bill a consult. (If the referring physician tells you to take over and manage the care of the patient, you cannot bill a consult). 2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record. This can be either verbal or written. But, either way, it should be documented in the patient's medical record by the requesting and the consulting physician. 2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record. This can be either verbal or written. But, either way, it should be documented in the patient's medical record by the requesting and the consulting physician. 3. After the consultation is provided, the consultant prepares a written report of their findings, which is provided to the referring physician. This report cannot be verbal. Copies of progress notes also cannot be used as the sole written report. 3. After the consultation is provided, the consultant prepares a written report of their findings, which is provided to the referring physician. This report cannot be verbal. Copies of progress notes also cannot be used as the sole written report.

Continued…. 4. Consult Followed by Treatment: If the referring physician does not transfer the responsibility of patient care to the receiving physician until after the consult service is completed, the receiving physician can bill a consult. After the consulting physician assumes responsibility for the patient care, subsequent visits should be reported as established patient visits or subsequent hospital care, depending on the setting. (This means that a physician can treat and consult on the same day, as long as they get back to the initial doctor before the treatment begins.) 5. Consult Requested by Member of Same Group Practice: Consultations may be requested within the same physician group practice. This may be done as long as all the requirements are met for use of the CPT consultation codes. 6. Documentation for Consult: The request for a consult from the attending and the need for a consult must be documented in the patient medical record. The consulting physician must provide a written report to the requesting physician for his/her use in treatment. In an inpatient setting, the request may be documented as part of a plan written in the requesting physician ’ s progress note, an order in a hospital record, or a specific written request for the consult. In an office setting, the requirement can be met by a specific reference to the request. 7. Consult for Preoperative Clearance: You can bill a consult for preoperative clearance for a new or established patient when the consult is done at the request of a surgeon. 8. Post-Op Care by Physician who did Preoperative Clearance Consult: After a physician completes a pre-op consult in the office or hospital, the physician should not bill another consult if he/she then assumes responsibility for the management portion or all of the patient ’ s condition(s) during the post-op period. In an in-patient setting, the physician who performed a pre-op consult and assumes responsibility of the management of a portion or all of the patient ’ s condition(s) during the post-op period should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she provides. In the office setting, physicians should use the appropriate established patient visit code during the post-op period. A primary care physician or specialist who performs a post-op evaluation of a new or established patient at the request of the surgeon may bill a consult for E&M services furnished during the post-op period following surgery as long as the physician did not already perform a pre-op consult. (This clarification, in June of 1996, states point-blank that a non-specialist can bill consults for pre-op care.) 9. Surgeon Requests Another Physician Participate in Post-Op Care: If the surgeon asks a physician who has not seen the patient for a pre-operative consult to take responsibility for the management of an aspect of the patient's condition during the post-op period, the physician may not bill a consult because the surgeon is not asking that physician's opinion or advice for the surgeon ’ s use in treating the patient. The physician ’ s service would constitute concurrent care and should be billed using the appropriate visit code.

What is the principal issue? The actual issue that has to be answered is whether there is a transfer of care. If the complete care of the patient’s problem has been turned over to the specialist and that specialist agrees to accept accountability for the patient’s care prior to an initial evaluation being performed then a consultation code cannot be billed.

When does Transfer of Care occur? “…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 the referral, and the receiving physician documents approval of care in advance…” [Medicare Carrier’s Manual, § (B)] “…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 the referral, and the receiving physician documents approval of care in advance…” [Medicare Carrier’s Manual, § (B)]

Examples of Transfer of Care Patient is seen by her family practice physician with complaints of wrist and hand pain, finger numbness and is suspected to have carpal tunnel syndrome. It is recommended to the patient to seek a hand surgeon’s care and treatment of possible carpel tunnel syndrome. Patient is seen by her family practice physician with complaints of wrist and hand pain, finger numbness and is suspected to have carpal tunnel syndrome. It is recommended to the patient to seek a hand surgeon’s care and treatment of possible carpel tunnel syndrome. Patient with a knee injury is treated by an Emergency Department physician. The patient is told to follow up with an orthopedic physician the next day. Patient with a knee injury is treated by an Emergency Department physician. The patient is told to follow up with an orthopedic physician the next day.

Consult vs. Referral Continued… An easy way to think about consults is the “3 R’s”---a Request, Rendering an opinion, and Reporting back to the attending physician. An easy way to think about consults is the “3 R’s”---a Request, Rendering an opinion, and Reporting back to the attending physician. Request: Can be written or verbal and also must be documented in the patient’s medical record. [MCM § (A)(2) and (D) and CPT Assistant November 1999] Don’t assume the request is acknowledged in the requesting physician’s medical record. Don’t assume the request is acknowledged in the requesting physician’s medical record. “Who may we thank for referring you?” on the patient demographics sheet should not be used as proof that a consultation was requested. Ask the patient if another physician has recommended the evaluation. “Who may we thank for referring you?” on the patient demographics sheet should not be used as proof that a consultation was requested. Ask the patient if another physician has recommended the evaluation. Just because the patient has a managed care referral/authorization form does not mean it is a consultation request. Just because the patient has a managed care referral/authorization form does not mean it is a consultation request.

Consult vs. Referral Continued… Rendering: The need for the consult, and also the history, exam and medical decision making components of the evaluation has to be documented in the patients medical record. Report: The requesting physician must be furnished with a written report. [MCM § (D). “…communicate findings and/or recommendations by written report to the requesting physician or other appropriate source.” [CPT Assistant, August 2001] *Documentation must be textbook perfect*

Consult vs. Referral Continued… Wording on the requesting physician’s documentation ought to include “requested consult from” or “sought advice from” instead of the usual “referred to” or “sent to”. Wording on the requesting physician’s documentation ought to include “requested consult from” or “sought advice from” instead of the usual “referred to” or “sent to”. If the referring physician tells the consulting physician to take over and manage the care of the patient, you CANNOT bill a consult. If the referring physician tells the consulting physician to take over and manage the care of the patient, you CANNOT bill a consult. This “hand-off” point is often where physicians run into a problem billing consults. Physicians will say “Take care of this patient” and refer the patient to another physician. This is a visit…not a consult! This “hand-off” point is often where physicians run into a problem billing consults. Physicians will say “Take care of this patient” and refer the patient to another physician. This is a visit…not a consult!

Consultation Request vs. Recommendation If the patient only wants a recommendation for someone their doctor trusts for services that this patient will be needing on their own in the future then the doctor providing this information is not asking for advice or opinion and this service is not considered a consultation.

Examples of non-consultation services Examples: The patient’s family practice physician was asked by the general surgeon to provide pre-operative clearance for the FP’s diabetic patient with CAD. After surgery, the surgeon asks the FP to assess the patient’s diabetic control for the remainder of the hospital stay. The initial hospital service by the FP cannot be a consultation because he provided the pre-op clearance consultation services. [MCM, § (G)] The patient’s family practice physician was asked by the general surgeon to provide pre-operative clearance for the FP’s diabetic patient with CAD. After surgery, the surgeon asks the FP to assess the patient’s diabetic control for the remainder of the hospital stay. The initial hospital service by the FP cannot be a consultation because he provided the pre-op clearance consultation services. [MCM, § (G)] *Note: The above is a requirement for Medicare only. CPT has not specified any rules regarding post-op consultations when pre-op clearance was performed by the same physician/group. There is a standing order in the hospital that when a patient experiences XYZ symptoms during the night, the Emergency Department physician (or internist or hospitalist) is called to assess the patient and provide treatment as necessary. Standing orders do not satisfy the criteria for a valid consultation request. [MCM § (J)] There is a standing order in the hospital that when a patient experiences XYZ symptoms during the night, the Emergency Department physician (or internist or hospitalist) is called to assess the patient and provide treatment as necessary. Standing orders do not satisfy the criteria for a valid consultation request. [MCM § (J)]

Types of Consultation Services Office or Outpatient ( ) Physician office Physician office Hospital observation services Hospital observation services Home services Home services Domiciliary, rest home and custodial care Domiciliary, rest home and custodial care Emergency department Emergency departmentExamples: Office consultation for 30 year-old female tennis player with sprain or contusion of the forearm. Office consultation for 30 year-old female tennis player with sprain or contusion of the forearm. Initial office consultation for a 60 year-old male with vascular necrosis of the left femoral head with increasing pain. Initial office consultation for a 60 year-old male with vascular necrosis of the left femoral head with increasing pain. Office consultation for independent medical evaluation of a patient with a history of complicated low back and neck problems with previous multiple failed back surgeries. Office consultation for independent medical evaluation of a patient with a history of complicated low back and neck problems with previous multiple failed back surgeries.

Types of Consultation Services Inpatient ( ) Hospital inpatients Hospital inpatients Nursing facilities Nursing facilities Partial hospital setting Partial hospital setting Examples: Hospital consultation for a 50 year-old female with incapacitating knee pain due to generalized rheumatoid arthritis. Hospital consultation for a 50 year-old female with incapacitating knee pain due to generalized rheumatoid arthritis. Hospital consultation for a 70 year-old diabetic female with gangrene of the foot. Hospital consultation for a 70 year-old diabetic female with gangrene of the foot. Hospital consultation for a 35 year-old multiple-trauma male patient with complex pelvic fractures to evaluate and formulate management of plan. Hospital consultation for a 35 year-old multiple-trauma male patient with complex pelvic fractures to evaluate and formulate management of plan.

Who Can Request a Consultation? A physician or other appropriate source may request a consultation. A physician or other appropriate source may request a consultation. *Medicare Carrier’s Manual, § (A)(1) What is an “other appropriate source?” What is an “other appropriate source?” “CPT guidelines do not set restrictions regarding individuals who may be considered an ‘appropriate source’…..Some common examples include a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech- language therapist, psychologist, social worker, lawyer or insurance company…” [CPT Assistant, September 2002]

Who Can Provide and Bill For Consultation Services? “Any procedure or service in any section of this book (CPT 2004) may be used to designate the services rendered by any qualified physician or other qualified healthcare professional.” [Introduction, CPT 2004 Professional Edition, page xiii] Primary care physicians Primary care physicians Specialists Specialists Nurse practitioners and physician assistants as long as the service is within the scope of practice in your state. Nurse practitioners and physician assistants as long as the service is within the scope of practice in your state.

Who Can Provide and Bill For Consultation Services? Primary Care Physicians: A pre-operative clearance evaluation is the most common consultation service provided by a PCP. A pre-operative clearance evaluation is the most common consultation service provided by a PCP. -PCP needs to evaluate the patient before surgery. The surgeon’s request to have this evaluation done is documented in the patient’s medical record. -A medically necessary evaluation is provided by the PCP. -A written report from the PCP showing the results of the evaluation and recommendation for surgery is given to the surgeon.

Who Can Provide and Bill for Consultation Services? Does not have to be a physician. Does not have to be a physician. “Non-physician practitioners, e.g., nurse practitioners, certified nurse mid-wives or physician assistants, may….also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of non-physician practitioner in the State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules.” [MCM § (C)] [CPT Assistant, January 2002, “Beyond the Ordinary: Coding ‘Challenging’ E/M Circumstances,” Case #2 – “The fact that this is an established patient of the family practitioner is irrelevant.”] Medicare agrees [MCM § (E) and (F)].

Unusual Consultation Requests Pre-surgical clearance from the PCP or specialist treating the condition. Pre-surgical clearance from the PCP or specialist treating the condition. Intra-specialty consultation requests (e.g., a gastroenterologist requests a consultation from a GI motility specialist). Intra-specialty consultation requests (e.g., a gastroenterologist requests a consultation from a GI motility specialist). [CPT Assistant, June 1999 and April 2000] Intra-specialty, intra-practice consultation requests (e.g., orthopedic surgeon requests consult from his/her spine specialist partner. Or a pediatrician requests a consult from his nurse practitioner who has special training in diagnosis and treatment of children with ADHD). Intra-specialty, intra-practice consultation requests (e.g., orthopedic surgeon requests consult from his/her spine specialist partner. Or a pediatrician requests a consult from his nurse practitioner who has special training in diagnosis and treatment of children with ADHD). [CPT Assistant, April 2000]

Use of Modifiers with Consultation Services -25 “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or other service. -25 “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or other service. * If there are diagnostic or therapeutic services that were performed on the same day as the consultation evaluation. * If there are diagnostic or therapeutic services that were performed on the same day as the consultation evaluation. -32 “Mandated Service” -32 “Mandated Service” *Should be used when the evaluation is required by a third party payer. -57 “Decision for Surgery” * Most often used for emergency room and inpatient consultations. * Use if the decision to immediately perform surgery was a result of the consultation evaluation.

Do’s and Don’ts of Consultation Billing DO Do check your state Medicaid and contracted managed care program definitions for consultation services, they may be different than CPT or Medicare’s definitions. Do check your state Medicaid and contracted managed care program definitions for consultation services, they may be different than CPT or Medicare’s definitions. Do document the request for advice or opinion in your medical record and be as specific as possible. Do document the request for advice or opinion in your medical record and be as specific as possible. Do promptly return a written report to the requesting physician with a copy of the report in your records. Do promptly return a written report to the requesting physician with a copy of the report in your records. Do charge for a consultation service when a surgeon asks you for surgical clearance. Do charge for a consultation service when a surgeon asks you for surgical clearance. Do charge for consultation services when a medically necessary opinion is sought from a physician of the same specialty as the requesting physician. Do charge for consultation services when a medically necessary opinion is sought from a physician of the same specialty as the requesting physician.

Do’s and Don’ts of Consultation Billing DON’T Don’t charge for a consultation when the patient comes to you for ER follow-up care. Don’t charge for a consultation when the patient comes to you for ER follow-up care. Don’t charge for a consultation when the patient has self referred to your practice. Don’t charge for a consultation when the patient has self referred to your practice. Don’t charge for a consultation when the patient received your name as just a recommendation from another physician. Don’t charge for a consultation when the patient received your name as just a recommendation from another physician. Don’t charge for a consultation every time a new managed care referral form is received. Don’t charge for a consultation every time a new managed care referral form is received. Don’t forget to make sure that the documentation supports all three “R’s.” If any one of the three are missing, according to both CPT and Medicare, the service must be charged as a regular office or hospital visit, regardless of the intent of the requesting physician. Don’t forget to make sure that the documentation supports all three “R’s.” If any one of the three are missing, according to both CPT and Medicare, the service must be charged as a regular office or hospital visit, regardless of the intent of the requesting physician.

Consultation Checklist Is this encounter a request for my advice or opinion? Is this encounter a request for my advice or opinion? Is the request for consultation documented in my copy of the medical record? Is the request for consultation documented in my copy of the medical record? Is the medical necessity for this service demonstrated and have I provided the key elements of E/M documentation to support the service that was billed? Is the medical necessity for this service demonstrated and have I provided the key elements of E/M documentation to support the service that was billed? Did the requesting physician or other appropriate source receive a written report and is there a copy of this report in my medical record? Did the requesting physician or other appropriate source receive a written report and is there a copy of this report in my medical record?

Documentation of an encounter dominated by counseling or coordination of care. In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to- face in the office or other outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M service. If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care. Time as the Main Component

TIME COMPONENT CodeTimeCodeTimeCodeTime min min min min min min min min min min min min min min min New Patient Established Patient Outpatient Consult

Contact Information Gary Cavett, CPA President 51 Broadway Suite 601 P.O. Box 2927 Fargo, ND Tel:(701) Fax:(701) Web site: