CODING Q& A

The Correct Procedure for Requesting Consultations

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. Differing opinions exist as to whether there has to be a written request from the physician requesting a consultation in my chart documentation. Some colleagues say requestors must provide the written request in a form that they prepare.What is correct?
A. This is still a work-in-progress, though it should not be. The original Medicare transmittal was issued in December 2005 and contained the following language: “A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
“The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan or care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.”
Thus, it appears that there must be a written request from the requestor in the consultant’s chart. However, it turns out this is not what was intended. On Nov. 14, 2006, Empire Medicare of New Jersey, a reliable and excellent carrier, published on its Web site a clarification on consultations. It may be accessed as follows: http://www.empiremedicare.com/ news/njnews06/111406con.htm.
Here is the part of the article dealing with our question:
“Empire Medicare Services has reviewed the documentation needed to support the use of a consultation code with CMS: The referral from the requesting provider may be in writing (eg, formal note/letter, requested on a prescription or other form, fax), or may be verbal. If verbal, it should be noted in the medical record of the requesting and performing providers. (We suggest a brief sentence to the effect, ‘Patient referred by Dr. Smith for consultation to evaluate [specify condition or symptoms]’ be included with the chief complaint or HPI.)”
It is insufficient documentation of a consultation service to only record the name of the referring provider in the patient billing record or on a patient intake sheet. A dated report of the consultation must be sent to the requesting provider. It should include the name of the patient and the requesting provider, and be signed by the consultant.
An entry in shared medical records (eg, group practice with common medical records, hospital or other facility, etc.) may suffice in lieu of a separate report.
Medicare contractors may request records from the provider requesting the consultation. Claims for consultation services not meeting these standards may be denied.
A protest was registered regarding the consultant being legally responsible for the chart documentation of another provider (ie, the requestor). At the Aug. 28, 2006 meeting of PPAC (Practicing Physicians Advisory Council), the PRIT (Physicians Regulatory Information Team) clarified what Empire Medicare has written. It was also stated that CMS was not going to hold the consultant responsible for the requestor’s chart documentation, but this has not yet been transmitted to the carriers.
Under audit, the auditor might be looking for that written request, and failing to find it, may downcode the encounter to an office visit rather than a consultation. I recommend that you have a written request from the requesting physician when at all possible for outside referrals.
Make sure your chief complaint is documented per Empire Medicare instructions. For requests for consultations among members of the same group (intra-office referrals), prepare a form to be used internally that contains the following information: date, name of requestor, name of consultant, and reason for the consultation. Your own practice chart must include a written request.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com.