Do you know your consultation codes?
By Marc Sencer, MD

Many doctors are confused about the use of the consultation codes, particularly in the group practice setting.

When is it appropriate to bill a consult and how should you document it? Do you know? Test your knowledge with today’s quiz.

You are the chiropractic physician in an integrated group practice consisting of a neurologist, a physiatrist, and yourself.

Of the following statements, which are correct regarding consultation codes 99241-45?

A. As a chiropractor, you may order a separate consultation with the neurologist, the physiatrist, or both.

B. For an established patient of your group who has already had an initial evaluation by you in the last three years, a first time visit with one of the MDs cannot be billed as an initial evaluation; it must be billed as a consult.

C. There is a no limit on the number of doctors in a group who may consult on a case.

D. Ideally, a consultation should include all of the following:

1 . The referring doctor notes the order and reason for the consult,

2. The report of consultation must name the referring doctor,

3. The referring doctor should note that he or she has reviewed the consultation report, and

4. The consulting doctor must return the patient to the referring doctor for ongoing care.

A is correct. A chiropractor may order a consultation with a medical physician of any specialty whether that physician is in or out of your group practice. This applies to all patients, including those on Medicare.

B is incorrect. The initial encounter with a different doctor in the group may be billed as a consult if it meets the documentation and medical necessity criteria for a consult. It may also be billed as an initial evaluation.

The rule is that only one initial evaluation per group tax ID number may be performed within a three year period by “physicians of the same specialty.” Since the MD is of a different specialty from the chiropractor, he may bill correctly for an initial evaluation. The different specialty exception would also apply if one initial consultation had been done by the neurologist and another by the physiatrist. However, billing as a consult will produce the best reimbursement.

C is also correct. Each specialist in a group practice may consult on a case if there is medical necessity for the consult, but be aware that Medicare states that within a group practice the use of consultations “shall not be abused.”

There should be clear medical necessity for each consult ordered and proper documentation. Any visits after the initial consult are billed as reevaluations. Always ask yourself if a potential consult will add anything of value to the case, either by assisting in making a diagnosis or influencing the treatment plan. These are the questions that CMS will ask in an audit!

D is both correct and incorrect. The first three are correct because these are the basic documentation requirements for the referring and consulting doctors, but No. 4 is not correct.

While the assumption for all consults is that after rendering an opinion the consulting doctor will send the patient back to the referring doctor, sometimes the consult result will be that one or more of the patient’s conditions will best be treated by the consulting doctor. For instance, a consulting neurologist may newly diagnose and decide to treat the patient’s migraines.

One advantage of an integrated practice is the ability to get the opinions of multiple specialists, and to be reimbursed for their services — just be sure you understand the rules!

Marc H. Sencer, MD, is the president and founder of MDs for DCs, which provides intensive one-on-one training, medical staffing, and on-going practice management support to chiropractic integrated practices. He can be reached at 800-916-1462 or www.mdsfordcs.com.