1. An Update on Consultations
Discrepancies in the documentation of medical consultations have prompted the Office of Inspector General to include a review of consultations in its 2002 workplan. Please note the following reminders as they will help in adhering to existing consultation guidelines and requirements.
The Centers for Medicare and Medicaid Services (CMS) defines consultations (codes 99241-99275) in Section 15506 of the Carriers Manual as follows:
Consultation Requirements- “…a consultation is distinguished from a visit because 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…”
- “…a request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.”
- “…After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.”
Example of Consultations—(provided by CMS)
An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. The patient exhibits a new skin lesion and the internist sends the patient to a dermatologist for further evaluation. The dermatologist examines the patient and removes the lesion, which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his evaluation and treatment of the patient.
The American Medical Association’s Current Procedural Terminology defines consultations (for the purposes of coding) in the same manner as above.
An easy way to remember what’s required when determining whether or not your service truly meets the definition of a consult as listed above is to look for “the Three R’s” that make up a consult:
- Request from another physician
- Rendering of your opinion/advice
- Report sent back to requesting physician
These three things must be reflected in your medical record documentation or the service does not meet the criteria.Caution: Referrals
Managed care referral authorizations from a patient’s PCP does not automatically justify use of a “consult” code; it’s essential that all criteria mentioned above be met. In the managed care environment the patient generally needs a referral from the PCP as gatekeeper to see a specialist; even for routine, annual or semi-annual follow-ups. Referrals geared toward supplying the insurance company with a referral number are not necessarily clear indications of a “request for advice/opinion.” These referral slips often lack clinical information indicating a request for advice/opinion or the condition. As a result, caution should be used selecting consult codes without documentation supporting the request and specific advice/opinion being sought.
For more information regarding consultations please contact Ed Keating (ext. 2-6064) Rhonda Flanagan (ext. 2-7851) or Neil Walsh (ext. 2-7868) in the Billing Compliance Office.
2. An Update on Laser Privileges
The credentialing process for laser privileges has been upgraded and is posted in BICS, similar to the practice for Intravenous Conscious Sedation (IVCS). This allows physicians to view when their privileges are due for renewal, and allows other caregivers such as OR staff to confirm that a physician has current privileges to perform laser procedures. The privilege information can be viewed in BICS, in either the CI or UT functions, by selecting “View Physician Directory” and then entering the name. The screen indicates whether the physician has laser privileges and if there is an expiration date.
Laser Privileges Credentials
- Laser privileges are granted independently of departmental credentialing procedures, and are granted only after meeting criteria established by the BWH Laser Safety Committee. These criteria include completion of a laser training course, a preceptor at the appropriate wavelength for three cases, and a baseline eye examination.
- Laser privileges renewal will be tied to the biannual reappointment cycle. Physicians must perform at least two laser procedures per year in order for privileges to be renewed, per criteria established by the BWH Laser Safety Committee.
This new process is effective immediately. Enhancements to the privileging process for fluoroscopy are planned as well. To request information on obtaining laser privileges or to learn about training courses, contact the Department of Surgery at ext. 2-8314.