Consultation Coding?

Can a specialist bill a consultation if a patient is required to attend a seminar explaining the process for certain procedures before scheduling an appointment with the specialist?

Would it be appropriate for the specialist to contact the primary care provider (PCP) after the patient attended the seminar to ask the PCP if they would like the specialist to see their patient in consultation to give their advice and opinion regarding which procedure option is most appropriate and then bill a consultation for this service?


Thanks,
Patti

Tough question

I occasionally get requests from specialists to write a "referral request" for a patient where the patient made the appointment and whom I had not seen them in months/years or even had seen recently but never discussed the problem warranting the specialist visit. I take offense to these requests- I am not a conduit to allow the specialists to make more money.
I have also seen specialists send me letters "thank you for referring Mr X for..." and when I review the chart I find the patient was not seen for months/years and certainly never had that problem in my visits. In these cases I am tempted to call CMS (Qui Tam pays well).
On the other hand, I occasionally casually suggest a patient see a specialist for an issue "you may want to see a dermatologist for that acne" but do not fax a referral request. In those cases I gladly comply.
In your case (and I am guessing) if it was an obese diabetic patient who I told to lose weight (as if that ever works..) and you saw the patient after a lap band seminar, I would be happy to send a referral request.

consultation coding

No, do not ask the PCP for a request. A consult is a request for an opinion, evaluation, advise. It is entirely inappropriate to ask another physician to request an opinion, after you have already seen the patient, or after the patient has called and asked for an appointment.

This is not a consult.

Be careful: a referral is not a request for an opinion.

This will not be billable under MediCare nor any Insurance co that I know of ..

Due to this being an optional Seminar. This would billable and can end being audited as "Fraud". To do a consult, a physician would send you request in regards to the patient's medical and the doctors' request of a more expect physician as a specialist. Also an consult can be in the same hospital or medical group by usually different specialties

A referral is for when a doctor transfer there patients' care to you.. usually if you have more expertise in an area that referring doctors skills are limited.

Per MediCare -

Appropriate Office or Other Outpatient Consultation codes (99241 – 99245) for an initial consultation in the office/outpatient setting.
Following the physician’s and qualified NPP’s initial consultation service, the follow-up visits should be reported using the:
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Subsequent Hospital Care codes (99231 – 99233) for the inpatient hospital setting; and
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Subsequent NF Care codes (99307 – 99310) in the NF setting; and
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Office or Other Outpatient Established Patient codes (99212 – 99215) should be reported for the office/outpatient setting.
Also, physicians and qualified NPPs need to be aware that:
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Medicare does not recognize CPT code 99211, a minimal service, for a consultation service as it would not meet the consultation criteria;
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An initial inpatient consultation will be reported only once per consultant per patient per facility admission;
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In an office or outpatient setting, if an additional request for a consultation, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation codes may be used again;
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If the consultant continues to care for the patient for the original condition following the initial consultation, repeat consultation services will not be reported by this physician or qualified NPP during his/her ongoing management of this condition;
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For a second opinion evaluation (patient and/or family requested) in the facility setting arranged through the attending physician, the evaluation is reported as an Initial Inpatient Consultation service if the consultation requirements are met;
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If the second opinion evaluation does not meet the consultation requirements, the Subsequent Hospital Care codes for the inpatient setting and Subsequent NF Care codes for the NF setting are reported;
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For a second opinion evaluation, report the Office or Other Outpatient codes (new or established patient as appropriate) for the office/outpatient settings;
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A written report is not required by Medicare to be sent to a physician or qualified NPP when a second opinion evaluation visit has been requested by the patient and/or family;
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The CPT Modifier - 32 (mandated services) is not recognized as a payment modifier in Medicare;
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations.