Compliance Focus: Consultations
The Centers for Medicare and Medicaid Services (CMS) defines consultations
(codes 99241-99275) in Section 15506 of the Carriers Manual as follows:
• “… it is provided by a physician whose opinion or advice
regarding evaluation and/or management of a specific problem is requested by another
physician or other appropriate source…”
• “…the need for consultation must be documented in the patient's
medical record.”
• “…the consultant prepares a written report of his/her findings
which is provided to the referring physician.”
An easy way to determine whether or not your service truly meets the definition
of a consult is to look for “the three R’s”, which must each
be reflected in your medical record documentation:
• Request from another physician
• Rendering of your opinion/advice
• Report sent back to requesting physician.
Note that managed care referral authorizations from a patient’s PCP alone
do not automatically justify use of a “consult” code without these
three criteria. These referrals supply the insurance company with a referral number
but often lack essential clinical information such as patient condition or a request
for opinion/advice.
For more information regarding consultations please contact Neil Walsh at 617-732-9377
or cwalsh6@partners.org.