This month’s Coding Nuggets were provided by Jeannie C. Cagle, R.N., CPC, a senior consultant of The Coker Group with more than 20 years experience in clinical health. The Coker Group is an SMA approved partner.

Question

My supervisor asked me to contact you about a question we have at our urology practice. What is the difference between a consult and a referral? A lot of times, a patient is referred to us for example- kidney stones.....Would it be fair to charge a consult? We usually continue to care for the patient for this problem- so after looking at some of the rules- it seems that since we continue to care for the problem that they were sent to us for- it seems that we can't charge a consult- we will have to use a new patient visit code.....is this correct??

• Answer

  First of all, just for clarification, a ‘referral’ is a term often used to indicate when the patients type of insurance coverage, such as a HMO or POS,  requires the primary physician to ‘refer’ the patient before they can see a specialist.  This is different from the requirements of a consult per CPT and CMS. 

  But I think your question is when should you use the CPT designation of a new patient (99201-99205) and when should you use the consult code (99241-99245).  Interestingly, that seems to be the question everybody is asking, including CMS.  The confusion was further perpetuated by Transmittal 788, published by CMS in January of 2006, that stated “A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition”.  That’s easy enough when a primary physician sends a female patient to an obstetrician for a new pregnancy and the primary doctor does not expect to continue treating or caring for the patient for that condition, but what about the case you mentioned, kidney stones?  Or what about a patient sent to your specialist by the primary physician for frequent UTI?

  The CPT Editorial Panel failed to reach a consensus on how to clarify the definition of consult at its February meeting, according to the Physician Regulatory Issues Team (PRIT) at CMS. That means there won’t be any clarification in the CPT 2008 update.

  One thing is very clear:  there must be documentation from the requesting provider asking that the patient be seen by a specific provider for a specific problem, the specialist must document their opinion of what should be done with recommendations for treatment, and that opinion must be communicated in writing back to the requesting provider.  Many specialty offices do not have a clear ‘circle’ of communication documented from the requesting physician to the specialist and back to the requesting physician.  For more information, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf

   

Question

In our specialty practice, we have a PA that sees first time office patients and takes a comprehensive history and performs a portion of the exam. Then the physician comes into the room after reviewing the PA’s documentation, performs additional elements to the exam and then documents the assessment and plan. Our physician has confidence in the work of the PA but I recently heard at a seminar that the PA and physician cannot share a consult. Is this true?

• Answer

  In the world of coding, so many things are gray but this is not one of them. CMS clearly states that consultations CANNOT be shared visits: Claims Processing 100-04 Chapter 12 Section 30.6.10 "A consultation shall not be performed as a split/shared E/M visit." Many practices will hire a Physician Assistant or Nurse Practitioner with the goal of reducing physician time and will use them in the manner you have described for consults but this is clearly a violation of the shared visit rule. Shared visits are described as documentation ‘shared’ by the PA/NP and the physician just as you have described, and the visit can be billed with the physician NPI. The shared visit applies to the following locations: hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge but not to consults or critical care. In the office, 'incident to' guidelines would apply. This information is located at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

   

Question

I know that we are supposed to have the nursing staff document per CMS guidelines three vital signs to support an element of the Constitutional exam. What are our choices for ‘vital signs’?

• Answer

  According to CMS examination guidelines, there are seven vital signs to choose from: height, weight, pulse, respirations, temperature, and blood pressure take one of two ways: supine and/or sitting/standing. Interestingly, BMI (body mass index) is not included as it is calculated by measuring the height and weight.