Despite clear guidelines from both the AMA and CMS defining what constitutes consultation codes, physicians seem to have a difficult time knowing when to use them — or, more to the point, when not to use them.
For several years the inappropriate use of consult codes was on the Office of Inspector General’s Workplan for Physicians watch list. In 2001, Medicare paid out more than $2 billion for these physician services, and double-digit percentages of these were perceived to have been assigned incorrectly.
Indeed, the outpatient and inpatient versions of consultation codes are very close in the description of physician work to the new-patient office visit codes. In fact, the physician work descriptions are identical when it comes to the components of history, exam, and decision-making.
The work components may be the same when it comes to the actual evaluation of the patient, but the payments aren’t the same — and there is a reason for that. Part of the work value of a consult code is the writing of a consult note, or report, which needs to be forwarded to the requesting physician. It is this extra bit of work that accounts for the slightly higher payment amounts associated with the consult codes.
It may also be this element that accounts for some of the misuse of the codes. It may be no accident that providers overuse the consult codes in lieu of the office visit codes, or in the inpatient setting instead of the appropriate inpatient code; they may simply be gravitating toward the higher payment.
Symptoms and myths
Some providers, specialists in particular, don’t have any new-patient codes on their productivity reports at the end of the month — all new visits are coded as consults. This may stem from a belief that as specialists, they provide consultative services and don’t do office visits. This is incorrect.
Some providers believe that when a patient is referred by another physician, the patient is entitled to a consult. Incorrect again — although true consults are technically also referrals, the word “referral” is generally read as “transfer of care.”
Some providers believe that if they write a note back to the referring provider they are entitled to the consult code. I frequently see letters back to the referring physician that begin with “Dear Dr. Jones, thank you for allowing me to participate in the care of Mrs. X,” followed by a description of the encounter elements and plans or treatments. The presence of this type of letter also does not make for a consult. Although it is courteous and professional, it is simply marketing — thanking that referral base, which feeds your specialty practice.
A true consult defined
We’ll start with the definition of a consult from the subsection guidance in the 2006 CPT Manual:
“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 another physician or other appropriate source.”
In this first and most important sentence, the AMA gives us the core of a consult — that your opinion or advice is requested. It doesn’t say it’s a consult when you offer it; it is when you are asked. It also doesn’t say that whenever a patient presents in some relation to an encounter with another provider that it is a consult — it clearly states that the nature of consult is dependent upon whether or not the other provider is seeking opinion or advice. So much for the first two myths noted above.
Let’s go on:
“A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”
