July 30, 2021 | By Scott Kraft, Auditing Specialist, DoctorsManagement
While payers have increasingly turned away from covering consultation services, this type of billing is not extinct yet.
Consultations can be done in the office and inpatient setting, and just as a refresher, are billed when a provider is requesting the professional opinion of a provider of a different specialty to inform his or her own care of the patient. Hence we have the three R’s – request, render, report.
While the purpose of the consultation is essentially to furnish a professional opinion of the patient’s case to the requesting physician, the consultant may, at his or her own discretion, continue to care for the patient. These concepts are not mutually exclusive – the consultant provides a report back to the requesting physician, noting that he or she will remain involved in the case.
The patient becomes an established patient to the consultant for purposes of follow-up visits.
As an auditor, I am often left trying to determine, from the documentation provided, whether the intent of the visit with the specialist is truly a consult or a referral. The consultant often views every eligible service as a consultation, even as the consultation rules make clear this is not the case.
It’s an important distinction – if the physician directs the patient to see a specialist for treatment, rather than a clinical opinion, by definition, it is not a consultation. That’s why the documentation of the consulting physician becomes important in signaling the true intent of the visit as accurately as possible.
For example, if the consultant’s documentation states in the history that the patient was referred for management or treatment of a specific condition, as documented this is not a consultation because the provider is essentially documenting that the patient is being sent for treatment.
Conversely, if the history states that the patient was sent by another provider for a consultation related to the condition, this meets the parameter of a consultation – even if the treatment decisions turn out to be exactly the same!
I’ve long believed that one of the reasons Medicare stopped paying for consultation services is that the rendering consultant may not always clearly understand these distinctions in documentation and what they mean. As auditors, whether or not we are able to credit a consultation is sometimes more of a byproduct of the language of the note than the intent of the service.
Auditors and providers should be trained to understand these distinctions and document and code based on the true intent of the service.
Another example I come across often is a patient who presents to the emergency department, is stabilized, and is then sent for follow-up with a specialist following discharge. Regardless of the structure of the note, I have a hard time seeing this as a consultation as emergency department physicians don’t intend to remain involved in the case.
As I often say in these instances, it is not that the emergency department physician doesn’t care about the patient’s ultimate outcome, but the emergency department physician isn’t looking for an opinion to inform the future treatment of the patient. Which means it is a referral, not a consultation.