Consult Documentation Guidelines

Categories:   Billing   Coding   Compliance   Documentation Guidelines   Medical Records   Medicare   Specialty Coding   Surgical Billing & Coding  

 

·         Medicare has made it very clear that consults CANNOT be shared between non-physician practitioners and physicians. If a non-physician practitioner performs any of the key elements of the consult, then the consult cannot be billed under the physician NPI. For commercial carriers, be sure and find out if these visits can be shared--don't just assume that they can.

·         Primary care or cardiology physicians who are asked to clear a patient for surgery can bill a consult code, even if the clearance is for an established patient. Remember that for Medicare patients, surgery clearance is only covered for patients with an underlying medical condition such as hypertension or diabetes that must be managed to safely perform surgery. Most carriers suggest the use of V72.83 diagnosis code for pre-operative surgery clearance. Remember that the requirements for written request from requesting physician and the need to send back your opinion to the requesting physician still apply.

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 

Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.