Evaluation and management (E/M) codes are among the major categories of codes that are frequently examined by third-party insurance auditors. Medicare auditors recently have seen many cases in which documentation guidelines are not followed adequately to support a consultation code.
The key reason the documentation is scrutinized is because the reimbursements for consultations are higher than the reimbursement levels for office visits of similar documentation levels. In most instances, if the guidelines were not accurately followed, the consultation was either downcoded or denied. In either case, money is taken back from the practice or the physician.
The office/outpatient consultation codes, 99241-99245, and the inpatient consultation codes, 99251-99255, may be used for either a new patient or an established patient. The inpatient consultation codes may also be used for places of service, such as nursing homes or a rehabilitation facility.
When physicians code a consultation, they should follow the three Rs:
Request. The consulting physician should receive a written request, including the reason for the consultation, from an appropriate source. Be sure it is documented properly and placed in the patient's medical record, as well as in the requesting physician's plan of care. If the physician is documenting in the chart by hand, the notes must be legible. If the notes are not legible, the visit will be treated as though there was no documentation and the visit did not happen, or the physicians will have their money taken back because the visit should not have been paid.
Before the consultation visit takes place, remember to follow this dual-documentation process: The requesting physician as well as the consulting physician should enclose the request and the reason for the consultation and document it in each of their charts.
Render an opinion or advice. The consulting physician must then render his or her opinion or advice concerning the patient's problem and document it in the patient's medical record.
Report information in a shared record. If the consulting physician does not share the patient's medical record with the requesting physician, then a letter must be sent to the requesting provider. In the case that the consulting physician does share the patient's medical record with the requesting provider, the report should be put into a shared record. The report should always include a thank-you letter for the consultation request and state exactly what the consultant's opinion is concerning the patient's medical problem.
Editor's Note: This article was adapted from one that originally appeared in the September 2008 issue of The Doctor's Office, a HealthLeaders Media publication.