Coding Q&A

Guidance on documentation for consultations


Guidance on Documentation for Consultations


Q. An endocrinologist sends a patient to us to evaluate for Background Diabetic Retinopathy (of course, the patient is a diabetic).

Do we charge for a consultation? The endocrinologist is asking our opinion as to whether this patient has that disease, yet when the patient goes back to the endocrinologist, the endocrinologist cannot manage for this. We do that. However, the endocrinologist does fill out a referral sheet asking us to see the patient for that specific reason.

A. There are several issues here to be addressed. First is the definition of a consultation. In order for a patient encounter to be coded as a consultation, the requestor must be asking for the opinion and advice of the consultant. If the patient is being referred for definitive care, then the encounter would be considered a referral.

The best place to document this is in the Chief Complaint/History of the Present Illness and the best way to do this is by a simple macro such as: Patient sent for evaluation of XXXXX (eg, possible retinal detachment, diabetic eye findings related to diabetes mellitus, etc.) by Dr. Smith. Auditors like to see the word "evaluation" and do not like the word "referral." By using this macro, you are setting the encounter up to be coded as a consultation, even if the final decision is to use another set of codes. This methodology has been confirmed to contractors/carriers by Medicare.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at

It is always better to have a written request for the consultation. Even though Medicare has stated that the consultant is not responsible for the chart documentation of the requestor, it will not fare well for you if there is no request for a consultation in the requestor's chart. This applies both to consultations requested by physicians outside of the practice and internally. You might be better served by calling your form a "consultation request." Keep a copy in your chart and, if audited, be sure to include a copy. Thus, you are covered even if the requestor did not include the documentation in the chart notes.

Whether or not you use an E/M consultation code or an Eye Code depends on various factors, including final complexity, Carrier/Contractor Local Coverage Determinations, and optimization of reimbursement.

The second issue is whether or not initiation of treatment or diagnostic tests renders the encounter an office visit rather than a consultation. The answer is absolutely not. This has never been part of Medicare's consultation policy despite widespread beliefs to the contrary.

Q. CMS is now requiring that to bill for a consultation we must maintain a written request for said consultation in our medical record. How should we deal with this new requirement?

A. This was partially addressed in the previous question. Let's now further clarify the regulation.

The request for the consultation should be written and specifically ask for the consultant's opinion and advice on a specific issue (reason for the consultation). The written request should be documented in both the provider's chart documentation notes and in the plan of the requesting physician. However, the written request can be formulated by the consultant and documented in the Chief Complaint/History of the Present Illness as described in the first answer.

PRIT (Physician's Regulatory Information Team), a group of CMS experts who work on regulatory matters, has clarified that Medicare does not expect the consulting physician to verify that the requesting physician has documented the consultation request in his/her patient's medical record, which many interpreted from the original document.

This is true for consultations provided by outside referral sources as well as by members of the same group (intraoffice consultations). This requirement is what is most often missing when I audit charts. A simple note stating "to retina" does not qualify. You should document that a consult is being requested, to whom, and for what reason.

CPT codes copyright 2006 American Medical Association. RP