Q:
I participated in your webinar in July regarding billing for consultation services in the private sector. I understood your comments about billing the consultation codes following the new CPT guidance as it relates to vasectomy and other common scenarios. However, in reference to your response to a question on whether physicians with the same tax ID can consult for each other, our understanding was that as long as their national provider identifiers were different, they could consult for each other. Also, regarding emergency room referrals being seen as new patients versus consults in the practice, we are seeing conflicting answers to this from our resource materials. You indicated that you can charge a consult from an ER physician referral. Can you direct us to documentation that supports your response?
A:
First, the CPT definition does not require a different specialty for a consult charge to be justified, nor does CPT require that a request comes from a separate tax ID, as the determination to take over care of a problem or patient can be made by any provider. You may recall that Medicare did allow intra-office consultation before blocking the use of consult codes. Private payers may have different rules and regulations, but CPT does not block the use of consult codes. Make sure that the requesting partner has clear documentation of the request for determination of whether the consulting physician should take over care of the patient, and make sure the consulting physician documentation is clear on the request for determination of care. With a shared medical record, no letter is required to notify the requesting physician of the determination.
As to your second question, you may recall that our answer in this regard was that charging the consult is probably allowed based on the new CPT description. For the purpose of the webinar, we were referencing the CPT manual section on the introduction to consultation codes. We would direct you to the CPT manual for the reference.
Payers can layer different rules on top of CPT. Medicare does not pay for consultation codes this year. If you want to find out the circumstances in which a payer will allow a consultation to be reported, you will need to check with the payer.
The CPT definition does, however, allow for a request for determination of a consultant to take over care of the patient; hence the possibility of payment for a consultation. The biggest problem for a consultation sent to the office by an ER physician is the communication back to the requesting provider. The ER physician does not intend to care for a patient once he leaves the ER; therefore, communication back to the ER doctor with findings and recommendations is not for the benefit of the ER doctor or the patient’s care. One could make the argument that continuity of care is served by this communication, but it would be difficult. Thus, meeting the definition is possible, but you must ask yourself: Does it meet the “intent,” or is the communication back to the ER physician “necessary”?
Q:
What documentation is required for billing of the post-void residual code 51798? I had heard that it was necessary to keep a copy of the printout from the machine in the patient chart.
A:
We could not find a requirement for inclusion of the printout from the PVR machine in the medical record. Although including the printout is recommended, only the results (mL of retained urine) and the need for the test must be recorded in the medical record.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.
