Can a provider within a group refer their patients to a specialist within the same group of providers and bill a consult?

28 Jan

Healthcare Fraud Shield Reader Question:  Can a provider within a group refer their patients to a specialist within the same group of providers and bill a consult?  The group consists of four internal medicine doctors, one family practice MD and one board certified endocrinologist.

Healthcare Fraud Shield Answer:  Consultation codes are an area of frequent billing errors, as they have specific documentation requirements that must be met for the codes to be used appropriately, no matter the practice setting.

First, the CPT code range for in-office or other outpatient consultations is 99241-99245.  The same code range is used for patients that are new to the specialist and for established patients who have seen the specialist previously, as a long a new request for consultation is made for each new or established consultation visit. 

Per CPT/AAPC Coder, there are three required components that must be met in order for a consultation code to be used:

  1. There must be a request for an opinion or advice, made by a provider (or other appropriate source) to the specialist/consulting physician. The request can be verbal or in writing, but must be documented in the patient’s record in order to be considered a valid consultation request. 

The consultation request is for the specialist’s advice or opinion only.  In the case of your multi-specialty office, the record must be very clear that the first provider is seeking the specialist’s advice or opinion about the patient’s specific condition.  If the record states something like “the patient is referred to Dr. X…”, this first requirement is not met and a consultation code cannot be used.

  1. The consulting specialist must come to an opinion or treatment recommendation about the patient’s specific problem or condition for which the consultation was requested. This finding must be documented in the consultant’s patient record.
  2. The consultant must prepare a written report of their finding(s) and recommendation(s), which must be provided to the requesting physician (or other appropriate source). This cannot be a “thanks for the referral” note, and it cannot be a copy of the history and physical.  The report must include information to assist the requesting physician in their treatment of the patient, and in specific response to the consultation request.

The transmission of the written report from the consultant to the requesting physician can be difficult to track within a group’s electronic medical record system.  You will need to verify the report was created by the consultant, and reviewed by the requesting physician.  As noted above, if the H&P is the only document sent from the consultant, the “written report” criteria is not met.

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