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Medical Conditions that Justify Billing for a Consultation

Medical coders and billers often have to justify the inclusion of another doctor’s consultation visit to the payer in a claim. A consultation visit is simply a visit that’s been requested by another physician, provider, or healthcare entity, such as a nurse practitioner, social worker, attorney, or even an insurance company.

With consultation visits, the most important thing for you to remember as a coder is to verify how the patient ended up seeing the physician. Most payers need to know that a visit to a consulting physician was medically necessary. In addition to detailing how the patient got connected to the consulting physician, the record must also document the request and reason for seeing the patient.

The consulting physician must then send a report of his findings to the provider or healthcare entity that requested the consultation. The consulting physician may order tests or therapy as long as everything he does is included in a report back to the requesting physician or entity.

This game of Who Got Here and How isn’t just confined to the clinical setting. It’s also a big part of how you code what goes down in a hospital.

When a physician puts on his consultation hat to see an inpatient, the request and reason for the consultation, as well as the consulting physician’s findings, must be part of the patient record, which is shared in the case of an inpatient. When all this information is included in the patient’s record, you can code such visits as consultation visits.

There is an exception: If the consulting physician will be assuming care of the patient, you can’t code the visit as a consulting visit. In that case, you use an inpatient code instead. Similarly, if all the treatment for a given problem is transferred to a consulting physician and he or she accepts the transfer before seeing the patient, the visit is not a consultation.

Consultation visits are often time-consuming. If the physician invests a lot of time discussing test results, treatment options, and the like with the patient, a time-based consultation may be billable. When choosing one of these codes, the total time of the visit, along with the amount of time spent in counseling the patient, must be documented with the other required information.

When documenting a time-based consultation visit, the record should indicate that at least half of the time reported was spent one-on-one with the patient, discussing test results, treatment options, and so on. A summary of the discussion should also be included in the record.

Be sure to verify whether a patient encounter is a consultation or a new patient visit. Consultation codes are the higher-paid E&M codes; therefore, solid documentation in the record is essential to support the additional reimbursement. If a consultation visit is missed, the reimbursement is lower than it should be.

Conversely, if the patient is actually a new patient or a referred patient, then the service has been over-billed. (A referred patient differs from a patient sent for a consultation in that the referring physician does not make the request in writing, and the second physician will not necessarily send a report to the first physician.)

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