Requests for Consult; Global Preventive Medicine Codes

February 4, 2013

Coding questions? We've got the answers.

Requests for Consult

Q: We have always asked our physicians to open their dictation with "consult requested by Dr. X for evaluation of Y." However some still do not.

Some hospital reports list a referring physician in the header of the consultation report and then the physician will write, "Thank you for the consultation," at the end, and "cc" the ordering physician.

Is the thank you and cc enough to meet the consultation criteria, as long as there is an order to back it up? Or must the documentation have an opening statement, which I prefer?

A: The CPT rule says that the request for the consult must be documented, but it doesn't say specifically where. The scenario you provide indicates that your question refers to an inpatient consult. In that case, the order for the consult will serve as the request, as it is a common medical record. Just including the thank you and cc is fine. In fact, you don't even need the cc on inpatient consults.

If it is an outpatient consult, however, the request must be documented somewhere, and it needs to indicate that the report was sent.

Global Preventive Medicine Codes and Specialists

Q: If a Medicare patient is seen by a gastroenterologist for a consult, should we bill a preventative code if it's decided that the patient should have a screening colonoscopy? We currently bill new or established patient codes. Can you please help?

A: This is a particularly thorny question. Medicare is of the opinion, and long has been, that if the referral is for a screening colonoscopy, then not only is there no consult, there should be no E&M billed, because the procedure is considered part of the work RVU for the scope. If for some reason the visit does not result in a colonoscopy appointment, then of course the E&M is billable.

The GI community has long held that a GI provider will determine whether the patient is an appropriate candidate for the procedure. Therefore, the GI community feels that since their opinion or advice is sought, it is a consult. The overriding fact is that CMS does the paying - so they get to decide. Strangely, commercial payers don't seem as opposed to either visits or consults in this scenario.

This question contains broader implications because it brings into play the use of global preventive medicine codes by specialists, which is problematic for a number of reasons. Although the CPT manual descriptions for codes 99381-99397 don't specify or exclude any specialties, since their inception, these codes have generally been recognized as representing the annual exam or health maintenance visit which addresses the entirety of the patient's health concerns. The CPT states specifically that the codes apply to infants, children, adolescents, and adults. It further references immunizations and counseling. It also refers to age- and gender-specific exam elements and requirements, but this seems to be in the context of the larger comprehensive evaluation.

A GI provider using the global preventive code when his interest is limited to a single organ system seems inconsistent with the code's intent. Similarly, OB/GYNs often use these codes when performing only the "well-woman" portion of a service. (Yes, I know that sometimes they perform the whole service.)

The issue is: Are these codes intended for specialty care? The commercial payers seem to say yes because they tend pay the specialty providers who bill for them. But at the end of the day, they will pay this code only once per year, regardless of what provider bills it. Who is the loser if the GI gets paid for the E&M related to a screening scope, and as a result, the family physician or internist is denied billing the service or won't provide the service? Consider this closely before using these codes as you suggest.

Macros and Documentation

Q: To simplify documentation requirements, I created a "macro" which states how much time I spend with patients and that at least 50 percent of the time is spent in counseling. The patients I see are complex and almost always have several diagnoses, both medical and psychiatric in nature. I typically use a 99214 code and my macro says that approximately 25 minutes is spent face-to-face with the patient and 50 percent of that time is spent in counseling. My calendar reflects that my appointments are generally at least 25 minutes long. What other documentation may be needed to protect me if I undergo a Medicare audit? How much detail about the counseling is required? Can the diagnoses and prescriptions primarily justify the time? Am I required to record check-in and check-out times? Do you have any other suggestions based on Medicare or CPT guidelines as to proper documentation guidelines when using time as the controlling factor for an office visit?

A: Many EHRs now have a generic macro that accomplishes what you state above, but you need to be careful with these. First, Medicare and the Office of Inspector General (OIG) have both expressed concern about overuse of macros, which is more than a trend in physician documentation; it is becoming an epidemic.

The 2011, 2012, and 2013 OIG Work Plan mentions "repetitive documentation." This indicates that any macro format needs subjective elements to take it from the generic and cookie-cutter to the specific. Medicare views the former as a medical necessity violation.

Specifically, you say that your macro says approximately 25 minutes with 50 percent of time spent counseling. I would not say approximately. The time spent counseling also needs to be over 50 percent. These are minor but important differences.

You go on to say that your calendar reflects generally at least 25 minutes total. These are not the words to use when someone is counting the beans. I realize that the CPT descriptions state "typical" times, and that one interpretation is that it is the closer of two typical times that apply when selecting a given code, but I would take the potentially narrower Medicare view and not waffle about times. Be precise.

You do not need to record the patient's time in and time out, but only the "over 50 percent" portion of the total time. As to the degree of detail on the content, just say it in English - e.g., "Spent over 50 percent of 25 minutes discussing medication management versus surgical options." Name the meds, name the surgery. Better yet, say "Spent all of a 30-minute visit with Betty and her daughter discussing X." Personalize it.

These days, Medicare would rather see subjective content than the macro. For best effect, integrate the time statement right into your assessment and plan.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the February 2013 issue of Physicians Practice.