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Frequently Asked Questions

Use of Consultation Codes

Medicare published a revision on the interpretation and use of consultations in August 1999. The dialog is found in the Medicare Carriers Manual Sec. B3 15506.

1. When does a consult become a referral?

Consults are for an opinion only. It becomes a referral when you take over care. The first visit would be a consultation as long as the requirements for consultation are met in the documentation. Requirements for a consult are verbal or written request, opinion & any services provided, and written report back to the requesting physician.

2. Can a physician initiate treatment as a consult?

Yes, a consultant may initiate diagnostic and/or therapeutic testing to reach an opinion. Consultants may initiate treatment.

3. In the inpatient setting, can the consulting physician subsequently manage the treatment plan as a consultant?

If the consulting physician were waiting for results the follow-up consultation codes would be appropriate. In all other cases, the subsequent management would be coded as concurrent care (daily hospital care).

4. In the inpatient setting, when does a follow-up consult become concurrent care or daily care?

When you assume care of all or a portion of the patientís care and stop rendering an opinion.

5. If a physician provides a consult to a requesting physician and subsequently is asked to see that patient again, is the subsequent visit a consult? Does the answer vary based on inpatient or an outpatient?

In the inpatient setting, depending on the request, this could be a follow-up consult or it could be concurrent care. Remember consultations are a method to gain an opinion. If you were being asked to take over a portion of the patientís care then you would bill concurrent care.

In the outpatient setting, it would be unusual to see a consult request for an opinion for a condition that already had a consult done for a specific problem. If however, some time had past and it was necessary to request another opinion then an outpatient consult could be appropriate. If the purpose is a transfer of care for that specific problem, the physician is taking over care and should bill an established patient E/M.

Use of Critical Care Codes

The AMA CPT 4 2000 edition includes changes to the definition of critical care codes.

1. Does a patient have to be "unstable" in order to bill critical care codes?

Medicare transmittal No. B-99-43 Dec 22, 1999 states that the term "unstable" is no longer used in the definition of CPT to describe critically ill or injured patients. The definition now states "A critical illness or injury acutely impairs one or more vital organ systems such that the patientís survival is jeopardized".

2. Is it appropriate to include procedures that are not bundled into the critical care code, into the total time billed for critical care?

No, procedures that are not bundled into the services provided in billing critical care should not be included in the total critical time but should be billed in addition to the critical care codes.