Often, at the time of a consultation, the specialist may spend a lot of time with the patient. The consulting physician may be offering alternative treatment methods, answering questions, or reviewing test results. When the majority of the visit time is spent on these activities, a consultation can be billed based on time.
The guidelines clearly illustrate the time elements that are customarily allotted for consultations. The outpatient consultations begin with 15 minutes for a Level 1 consultation (99241) and can involve as much as 80 minutes for 99245 if the service is medically necessary. The inpatient consultation times range from 20 minutes (99251) to 110 for the highest service level (99255).
When documenting a consultation based on the time allotment, the physician must still illustrate who requested the consultation and why. Then she should document all of the history, physical, and decision-making done during the visit. But the required elements for billing based on time also include documenting the total time spent with the patient. The note must also clearly state that at least half of that total time was spent in one of the aforementioned activities (question/answer, counseling, results review, etc.).
A summary of that discussion must be produced. This should detail what was discussed, which tests were reviewed, the questions asked, and any other pertinent information obtained during that time. If the documentation includes all of these elements, the service can then be billed at the level based on time, and not by using the history, physical, and medical decision-making elements alone.
Consultations are among the higher-paying evaluation and management (E/M) services. For this reason, offices want to bill them as often as possible. The Office of the Inspector General (OIG) has had consultations in its work plan for several years. Conducting regular audits of your office’s consultation billing (and even the accuracy of your new-patient billing) will help to assure complete compliance with the guidelines.
You need to make certain that all of the guidelines for your practice’s consults are being closely followed and monitored.
The most common mistake practices make is failing to report back to the requesting physician. Physicians must make certain they are closing the documentation loop so that the billing is appropriately substantiated.
A defined protocol should be established in your office to determine when a consultation is appropriate to bill. This should include a verification mechanism for determining the requester’s intent for the visit. Is it a transfer of care (new patient) or a consultation? The letter/report back to the requesting physician must also be strictly adhered to in order to comply with the guidelines. The established protocol should be monitored and then, as mentioned, audited on a regular basis.
Audits can be done internally, or an external auditor can be hired for the task. Whichever method is selected, the results should be tracked and filed, and recommendations should be implemented immediately.
Specialists see many patients in consultation. PCPs may even see a consultation when a surgeon is requesting surgical clearance. The codes, when appropriate for the services provided, pay a higher reimbursement, and thus carry specific guidelines. Hopefully, all the parties in the office are now a little more aware of the important differences between a consultation and a referral.
Suzan Hvizdash, CPC, is the physician educator for the department of
surgery at UPMC in Pittsburgh. A former member of the American Academy of Professional Coders’ national advisory board, Hvizdash holds the following
credentials: CPC, CPC-EMS, CPC-EDS, and CPC-EMA. She can be reached
via editor@physicianspractice.com.
This article originally appeared in the November 2007 issue of Physicians Practice.
