Developing an E&M Chart Review Process

Developing an E&M Chart Review Process

Presented by:Gary Cavett, CPA

President

Find out more at www.gmcavett.com

Audit vs. Audit vs. ReviewReview

AuditAudit Provides a reasonable basis for expressing Provides a reasonable basis for expressing

an opinionan opinion Detailed, independent testing proceduresDetailed, independent testing procedures Verification and substantiation proceduresVerification and substantiation procedures

May include direct correspondence with May include direct correspondence with creditors or debtors to verify details of creditors or debtors to verify details of amounts owed, physical inspection of amounts owed, physical inspection of inventories or investment securities, inspection inventories or investment securities, inspection of minutes and contractsof minutes and contracts

Give auditor knowledge and understanding of the Give auditor knowledge and understanding of the entities system of internal controlentities system of internal control

ReviewReview Does not provide a basis for the expression of an Does not provide a basis for the expression of an

opinionopinion Does not contemplate obtaining an understanding of Does not contemplate obtaining an understanding of

the internal control structure or assess control riskthe internal control structure or assess control risk Requires inquiry and analytical proceduresRequires inquiry and analytical procedures

Focus on information your company provides that Focus on information your company provides that doesn’t validate if the underlying transactions doesn’t validate if the underlying transactions represented by your organization’s financial represented by your organization’s financial statements are correctstatements are correct

No source document testing is performedNo source document testing is performed Less in scope than an auditLess in scope than an audit Does not require an opinion as to the records like an Does not require an opinion as to the records like an

audit doesaudit does

E&M UtilizationE&M Utilization

Category Descriptions FP IM OrthoNew Office Visits to All E/M Codes 2.71% 1.56% 12.14%Established Office Visits to All E/M codes 66.99% 49.39% 69.06%Initial Hospital Visits to All E/M Codes 2.74% 4.28% 1.02%Established Hospital Visits to All E/M Codes 12.51% 27.24% 2.54%Outpatient Consults to All E/M Codes 0.55% 1.01% 10.88%Inpatient Consults to All E/M Codes 0.35% 1.53% 3.68%Follow-up Consults to All E/M Codes 0.00% 0.00% 0.00%Confirmatory Consults to All E/M Codes 0.00% 0.00% 0.00%Emergency Department Services to All E/M Codes 2.17% 0.93% 0.27%Comprehensive Nursing Home Visits to All E/M Codes 0.87% 0.86% 0.04%Subsequent Nursing Home Visits to All E/M Codes 6.41% 6.26% 0.14%

All Office Visits to All E/M Codes 69.70% 50.96% 81.20%All Hospital Visits to All E/M Codes 15.25% 31.51% 3.56%All Consults to All E/M Codes 0.90% 2.55% 14.55%All Nursing Home Visits to All E/M Codes 7.28% 7.12% 0.18%

44.50% 52.70% 32.00%All E/M Visits to All Procedures 44.50% 52.70% 32.00%

Inter-category Utilization Inter-category Utilization (2007)(2007)

ESTABLISHED PATIENT UTILIZATION 1994 1997 2000 200899211

Family Practice 4.37% 3.94% 3.65% 1.10%Internal Medicine 4.31% 4.35% 4.34% 5.34%Ortho. Surg 4.17% 2.39% 1.86% 4.21%

99212Family Practice 22.78% 19.17% 17.90% 24.18%Internal Medicine 12.15% 10.40% 10.66% 5.15%Ortho. Surg 36.39% 31.58% 33.10% 7.42%




Code RVUs Code RVUs99201 0.99 99241 1.3499202 1.73 99242 2.4999203 2.56 99243 3.4299204 3.92 99244 5.0499205 4.93 99245 6.26

Code RVUs Code RVUs99211 0.55 99251 1.3199212 1.02 99252 2.0999213 1.66 99253 3.199214 2.52 99254 4.4699215 3.42 99255 5.55

New Office Visit Outpatient Consult

Inpatient ConsultEstablished Office Visit

E&M Relative Value UnitsE&M Relative Value Units

ConsultConsultvs. vs.

ReferralReferral

Definition of a ConsultationDefinition of a Consultation

““A consultation is a type of service provided by A consultation is a type of service provided by a physician whose opinion or advice regarding a physician whose opinion or advice regarding evaluation and/or management of a specific evaluation and/or management of a specific problem is requested by a physician or other problem is requested by a physician or other appropriate source.” [CPT, 2004]appropriate source.” [CPT, 2004]

““Specifically, a consultation is distinguished Specifically, a consultation is distinguished from a visit because it is provided by a from a visit because it is provided by a physician whose opinion or advice regarding physician whose opinion or advice regarding evaluation and/or management of a specific evaluation and/or management of a specific problem is requested by another physician or problem is requested by another physician or other appropriate source [Medicare Carriers other appropriate source [Medicare Carriers Manual, §15506 (A)(1)]Manual, §15506 (A)(1)]

Facts about Consultation Facts about Consultation ServicesServices

If the diagnosis is known, it can still be If the diagnosis is known, it can still be considered a consultation.considered a consultation.

If diagnostic or therapeutic treatment is If diagnostic or therapeutic treatment is started by the consulting physician during started by the consulting physician during the initial evaluation it is deemed a the initial evaluation it is deemed a consultation.consultation.

Primary care physicians, nurse practitioners, Primary care physicians, nurse practitioners, PAs, clinical nurse specialists and certified PAs, clinical nurse specialists and certified nurse midwives can also bill for consultation nurse midwives can also bill for consultation services.services.

Requesting and consulting physicians do not Requesting and consulting physicians do not have to be of different specialties.have to be of different specialties.

Facts about Consultation Facts about Consultation Services continued…Services continued…

Even though you’ve seen a patient with a condition Even though you’ve seen a patient with a condition and previously charged for a consult, you can bill for and previously charged for a consult, you can bill for a consult again on the same condition when a new a consult again on the same condition when a new request is made for your advice or opinion by the request is made for your advice or opinion by the attending provider.attending provider.

Even if a patient has previously been charged for a Even if a patient has previously been charged for a consultation relative to a condition, that same patient consultation relative to a condition, that same patient can be charged a consultation again for the same can be charged a consultation again for the same condition if a request for another consultation is condition if a request for another consultation is made by the attending physician.made by the attending physician.

Inpatient consults need to be billed for evaluation and Inpatient consults need to be billed for evaluation and management services provided in a hospital or similar management services provided in a hospital or similar setting, even when the physician takes over managing setting, even when the physician takes over managing an aspect of the patient’s care.an aspect of the patient’s care.

Referral for medical management from a surgeon to Referral for medical management from a surgeon to another physician is another physician is notnot a consultation. a consultation.

MEDICARE INSTRUCTION ON BILLING FOR MEDICARE INSTRUCTION ON BILLING FOR CONSULTATIONS AUGUST, 1999CONSULTATIONS AUGUST, 1999

ConsultationConsultation - An E&M service provided by a - An E&M service provided by a physician whose opinion or advice of a specific physician whose opinion or advice of a specific problem is requested by another physician or problem is requested by another physician or other appropriate source.other appropriate source.

Codes 99241-99255Codes 99241-99255

1. 1. Consult vs. VisitConsult vs. Visit: The consultant prepares a report of his/her findings, : The consultant prepares a report of his/her findings, provided to the referring physician, for the referring physician’s use in provided to the referring physician, for the referring physician’s use in treating the patient. A consultant may initiate diagnostic and/or therapeutic treating the patient. A consultant may initiate diagnostic and/or therapeutic services. However, when the referring physician services. However, when the referring physician transferstransfers the responsibility the responsibility for treatment to the receiving physician at the time of the referral in writing for treatment to the receiving physician at the time of the referral in writing or verbally, the receiving physician may not bill a consult. (If the referring or verbally, the receiving physician may not bill a consult. (If the referring physician tells you to take over and manage the care of the patient, you physician tells you to take over and manage the care of the patient, you cannot bill a consult).cannot bill a consult).

2. A request for a consultation from an appropriate source and the need for 2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record. This can consultation must be documented in the patient’s medical record. This can be either verbal or written. But, either way, it should be documented in the be either verbal or written. But, either way, it should be documented in the patient's medical record by the requesting and the consulting physician.patient's medical record by the requesting and the consulting physician.

3. After the consultation is provided, the consultant prepares a written 3. After the consultation is provided, the consultant prepares a written report of their findings, which is provided to the referring physician. This report of their findings, which is provided to the referring physician. This report cannot be verbal. Copies of progress notes also cannot be used as the report cannot be verbal. Copies of progress notes also cannot be used as the sole written report.sole written report.

Continued….Continued….

44. . Consult Followed by TreatmentConsult Followed by Treatment: If the referring physician does not transfer the : If the referring physician does not transfer the responsibility of patient care to the receiving physician until after the consult service responsibility of patient care to the receiving physician until after the consult service is completed, the receiving physician can bill a consult. After the consulting physician is completed, the receiving physician can bill a consult. After the consulting physician assumes responsibility for the patient care, subsequent visits should be reported as assumes responsibility for the patient care, subsequent visits should be reported as established patient visits or subsequent hospital care, depending on the setting. (This established patient visits or subsequent hospital care, depending on the setting. (This means that a physician can treat and consult on the same day, as long as they get means that a physician can treat and consult on the same day, as long as they get back to the initial doctor before the treatment begins.)back to the initial doctor before the treatment begins.)

5. 5. Consult Requested by Member of Same Group PracticeConsult Requested by Member of Same Group Practice: Consultations may be : Consultations may be requested within the same physician group practice. This may be done as long as all requested within the same physician group practice. This may be done as long as all the requirements are met for use of the CPT consultation codes.the requirements are met for use of the CPT consultation codes.

6. 6. Documentation for ConsultDocumentation for Consult: The request for a consult from the attending and the need : The request for a consult from the attending and the need for a consult must be documented in the patient medical record. The consulting for a consult must be documented in the patient medical record. The consulting physician must provide a written report to the requesting physician for his/her use in physician must provide a written report to the requesting physician for his/her use in treatment. In an inpatient setting, the request may be documented as part of a plan treatment. In an inpatient setting, the request may be documented as part of a plan written in the requesting physician’s progress note, an order in a hospital record, or a written in the requesting physician’s progress note, an order in a hospital record, or a specific written request for the consult. In an office setting, the requirement can be specific written request for the consult. In an office setting, the requirement can be met by a specific reference to the request.met by a specific reference to the request.

7. 7. Consult for Preoperative ClearanceConsult for Preoperative Clearance: You can bill a consult for preoperative clearance : You can bill a consult for preoperative clearance for a new or established patient when the consult is done at the request of a surgeon.for a new or established patient when the consult is done at the request of a surgeon.

8. 8. Post-Op Care by Physician who did Preoperative Clearance ConsultPost-Op Care by Physician who did Preoperative Clearance Consult: After a physician : After a physician completes a pre-op consult in the office or hospital, the physician should not bill completes a pre-op consult in the office or hospital, the physician should not bill another consult if he/she then assumes responsibility for the management portion or another consult if he/she then assumes responsibility for the management portion or all of the patient’s condition(s) during the post-op period. In an in-patient setting, the all of the patient’s condition(s) during the post-op period. In an in-patient setting, the physician who performed a pre-op consult and assumes responsibility of the physician who performed a pre-op consult and assumes responsibility of the management of a portion or all of the patient’s condition(s) during the post-op period management of a portion or all of the patient’s condition(s) during the post-op period should use the appropriate subsequent hospital care codes to bill for the concurrent should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she provides. In the office setting, physicians should use the appropriate care he or she provides. In the office setting, physicians should use the appropriate established patient visit code during the post-op period. A primary care physician or established patient visit code during the post-op period. A primary care physician or specialist who performs a post-op evaluation of a new or established patient at the specialist who performs a post-op evaluation of a new or established patient at the request of the surgeon may bill a consult for E&M services furnished during the post-request of the surgeon may bill a consult for E&M services furnished during the post-op period following surgery as long as the physician did not already perform a pre-op op period following surgery as long as the physician did not already perform a pre-op consult. (This clarification, in June of 1996, states point-blank that a non-specialist can consult. (This clarification, in June of 1996, states point-blank that a non-specialist can bill consults for pre-op care.)bill consults for pre-op care.)

9. 9. Surgeon Requests Another Physician Participate in Post-Op CareSurgeon Requests Another Physician Participate in Post-Op Care: If the surgeon asks a : If the surgeon asks a physician who has not seen the patient for a pre-operative consult to take physician who has not seen the patient for a pre-operative consult to take responsibility for the management of an aspect of the patient's condition during the responsibility for the management of an aspect of the patient's condition during the post-op period, the physician may not bill a consult because the surgeon is not asking post-op period, the physician may not bill a consult because the surgeon is not asking that physician's opinion or advice for the surgeon’s use in treating the patient. The that physician's opinion or advice for the surgeon’s use in treating the patient. The physician’s service would constitute concurrent care and should be billed using the physician’s service would constitute concurrent care and should be billed using the appropriate visit code.appropriate visit code.

What is the principal What is the principal issue?issue?

The actual issue that has to be answered The actual issue that has to be answered is whether there is a is whether there is a transfer of caretransfer of care. . If the If the complete care complete care of the patient’s of the patient’s problem has been turned over to the problem has been turned over to the specialist and that specialist agrees to specialist and that specialist agrees to accept accountability for the patient’s accept accountability for the patient’s care prior to an initial evaluation being care prior to an initial evaluation being performed then a consultation code performed then a consultation code cannot cannot be billed.be billed.

When does Transfer of Care When does Transfer of Care occur?occur?

“…“…A transfer of care occurs when the A transfer of care occurs when the referring physician transfers the referring physician transfers the responsibility for the patient’s complete responsibility for the patient’s complete care to the receiving physician at the time care to the receiving physician at the time of the referral, and the receiving physician of the referral, and the receiving physician documents approval of care in advance…” documents approval of care in advance…” [Medicare Carrier’s Manual, § 15506 (B)][Medicare Carrier’s Manual, § 15506 (B)]

Examples of Transfer of Examples of Transfer of CareCare

Patient is seen by her family practice Patient is seen by her family practice physician with complaints of wrist and hand physician with complaints of wrist and hand pain, finger numbness and is suspected to pain, finger numbness and is suspected to have carpal tunnel syndrome. It is have carpal tunnel syndrome. It is recommended to the patient to seek a hand recommended to the patient to seek a hand surgeon’s care and treatment of possible surgeon’s care and treatment of possible carpel tunnel syndrome.carpel tunnel syndrome.

Patient with a knee injury is treated by an Patient with a knee injury is treated by an Emergency Department physician. The Emergency Department physician. The patient is told to follow up with an orthopedic patient is told to follow up with an orthopedic physician the next day.physician the next day.

Consult vs. ReferralConsult vs. ReferralContinued…Continued…

An easy way to think about consults is the “An easy way to think about consults is the “3 R’s3 R’s”---a ”---a RRequestequest,, RRenderingendering an opinion, and an opinion, and RReportingeporting back back to the attending physician. to the attending physician.

Request:Request: Can be written or verbal and also must be Can be written or verbal and also must be documented in the patient’s medical record. [MCM documented in the patient’s medical record. [MCM § § 15506 (A)(2) and (D) and CPT Assistant November 15506 (A)(2) and (D) and CPT Assistant November 1999]1999]

• • Don’t assume the request is acknowledged in the Don’t assume the request is acknowledged in the requesting physician’s medical record.requesting physician’s medical record.

• “ • “Who may we thank for referring you?” on the Who may we thank for referring you?” on the patient patient demographics sheet should not be used demographics sheet should not be used as proof that a as proof that a consultation was requested. Ask the consultation was requested. Ask the patient if another physician patient if another physician has recommended the has recommended the evaluation.evaluation.

• • Just because the patient has a managed care Just because the patient has a managed care referral/authorization form does referral/authorization form does not not mean mean

it is a it is a consultation request. consultation request.


Rendering:Rendering: The need for the consult, The need for the consult, and also the history, exam and medical and also the history, exam and medical decision making components of the decision making components of the evaluation has to be documented in evaluation has to be documented in the patients medical record.the patients medical record.

Report:Report: The requesting physician must The requesting physician must be furnished with a written report. be furnished with a written report. [MCM [MCM § § 15506 (D). 15506 (D). “…communicate “…communicate findings and/or recommendations by findings and/or recommendations by written report to the requesting written report to the requesting physician or other appropriate physician or other appropriate source.” [CPT Assistant, August 2001]source.” [CPT Assistant, August 2001]*Documentation must be textbook *Documentation must be textbook perfect*perfect*


Wording on the requesting physician’s Wording on the requesting physician’s documentation ought to include “requested documentation ought to include “requested consult from” or “sought advice from” instead consult from” or “sought advice from” instead of the usual “referred to” or “sent to”. of the usual “referred to” or “sent to”.

If the referring physician tells the consulting If the referring physician tells the consulting

physician to take over and manage the care of physician to take over and manage the care of the patient, you CANNOT bill a consult. the patient, you CANNOT bill a consult.

This “hand-off” point is often where This “hand-off” point is often where physicians run into a problem billing consults. physicians run into a problem billing consults. Physicians will say “Take care of this patient” Physicians will say “Take care of this patient” and refer the patient to another physician. and refer the patient to another physician. This is a visit…not a consult!This is a visit…not a consult!

Consultation Request vs. Consultation Request vs. RecommendationRecommendation

If the patient only wants a If the patient only wants a recommendationrecommendation for someone their for someone their doctor trusts for services that this patient doctor trusts for services that this patient will be needing on their own in the future will be needing on their own in the future then the doctor providing this then the doctor providing this information is information is not not asking for advice or asking for advice or opinion and this service is not considered opinion and this service is not considered a consultation.a consultation.

Examples of non-Examples of non-consultation servicesconsultation services

Examples:Examples: The patient’s family practice physician was asked by the The patient’s family practice physician was asked by the

general surgeon to provide pre-operative clearance for the general surgeon to provide pre-operative clearance for the FP’s diabetic patient with CAD. After surgery, the surgeon FP’s diabetic patient with CAD. After surgery, the surgeon asks the FP to assess the patient’s diabetic control for the asks the FP to assess the patient’s diabetic control for the remainder of the hospital stay. The initial hospital service remainder of the hospital stay. The initial hospital service by the FP cannot be a consultation because he provided by the FP cannot be a consultation because he provided the pre-op clearance consultation services. [MCM, the pre-op clearance consultation services. [MCM, § § 15506 15506 (G)](G)]

*Note: The above is a requirement for Medicare only. CPT *Note: The above is a requirement for Medicare only. CPT has not specified any rules regarding post-op consultations has not specified any rules regarding post-op consultations when pre-op clearance was performed by the same when pre-op clearance was performed by the same physician/group.physician/group.

There is a standing order in the hospital that when a There is a standing order in the hospital that when a patient experiences XYZ symptoms during the night, the patient experiences XYZ symptoms during the night, the Emergency Department physician (or internist or Emergency Department physician (or internist or hospitalist) is called to assess the patient and provide hospitalist) is called to assess the patient and provide treatment as necessary. Standing orders do not satisfy the treatment as necessary. Standing orders do not satisfy the criteria for a valid consultation request. [MCM criteria for a valid consultation request. [MCM § § 15506 (J)]15506 (J)]

Types of Consultation Types of Consultation ServicesServices

Office or Outpatient (99241-99245)Office or Outpatient (99241-99245) Physician officePhysician office Hospital observation servicesHospital observation services Home servicesHome services Domiciliary, rest home and custodial care Domiciliary, rest home and custodial care Emergency departmentEmergency department

Examples:Examples: Office consultation for 30 year-old female tennis Office consultation for 30 year-old female tennis

player with sprain or contusion of the forearm.player with sprain or contusion of the forearm. Initial office consultation for a 60 year-old male Initial office consultation for a 60 year-old male

with vascular necrosis of the left femoral head with with vascular necrosis of the left femoral head with increasing pain.increasing pain.

Office consultation for independent medical Office consultation for independent medical evaluation of a patient with a history of evaluation of a patient with a history of complicated low back and neck problems with complicated low back and neck problems with previous multiple failed back surgeries.previous multiple failed back surgeries.

Types of Consultation Types of Consultation ServicesServices

Inpatient (99251-99255)Inpatient (99251-99255) Hospital inpatientsHospital inpatients Nursing facilitiesNursing facilities Partial hospital settingPartial hospital setting

ExamplesExamples:: Hospital consultation for a 50 year-old female Hospital consultation for a 50 year-old female

with incapacitating knee pain due to with incapacitating knee pain due to generalized rheumatoid arthritis.generalized rheumatoid arthritis.

Hospital consultation for a 70 year-old diabetic Hospital consultation for a 70 year-old diabetic female with gangrene of the foot.female with gangrene of the foot.

Hospital consultation for a 35 year-old Hospital consultation for a 35 year-old multiple-trauma male patient with complex multiple-trauma male patient with complex pelvic fractures to evaluate and formulate pelvic fractures to evaluate and formulate management of plan.management of plan.

Who Can Request a Who Can Request a Consultation?Consultation?

A physician or other appropriate source may A physician or other appropriate source may request a consultation.request a consultation.

*Medicare Carrier’s Manual, *Medicare Carrier’s Manual, §§15506 (A)15506 (A)(1)(1)

What is anWhat is an “other appropriate source?”“other appropriate source?”““CPT guidelines do not set restrictions CPT guidelines do not set restrictions regarding individuals who may be considered regarding individuals who may be considered an ‘appropriate source’…..Some common an ‘appropriate source’…..Some common examples include a physician assistant, nurse examples include a physician assistant, nurse practitioner, doctor of chiropractic, physical practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-therapist, occupational therapist, speech-language therapist, psychologist, social language therapist, psychologist, social worker, lawyer or insurance company…” worker, lawyer or insurance company…” [CPT [CPT Assistant, September 2002]Assistant, September 2002]

Who Can Provide and Bill Who Can Provide and Bill For Consultation For Consultation

Services?Services?““Any procedure or service in any section of this book Any procedure or service in any section of this book

(CPT 2004) may be used to designate the services (CPT 2004) may be used to designate the services rendered by any qualified physician or other rendered by any qualified physician or other qualified healthcare professional.” qualified healthcare professional.” [Introduction, CPT [Introduction, CPT 2004 Professional Edition, page xiii] 2004 Professional Edition, page xiii]

Primary care physiciansPrimary care physicians SpecialistsSpecialists Nurse practitioners and physician Nurse practitioners and physician

assistants as long as the service is within assistants as long as the service is within the scope of practice in your state.the scope of practice in your state.

Who Can Provide and Bill Who Can Provide and Bill For Consultation For Consultation

Services?Services?Primary Care PhysiciansPrimary Care Physicians::

A pre-operative clearance A pre-operative clearance evaluation is the most common evaluation is the most common consultation service provided by a PCP.consultation service provided by a PCP.

-PCP needs to evaluate the patient before -PCP needs to evaluate the patient before surgery. The surgeon’s request to have this surgery. The surgeon’s request to have this evaluation done is documented in the patient’s evaluation done is documented in the patient’s medical record.medical record.

-A medically necessary evaluation is provided -A medically necessary evaluation is provided by the PCP.by the PCP.

-A written report from the PCP showing the -A written report from the PCP showing the results of the evaluation and recommendation for results of the evaluation and recommendation for surgery is given to the surgeon.surgery is given to the surgeon.

Who Can Provide and Bill Who Can Provide and Bill for Consultation for Consultation

Services?Services? Does not have to be a physicianDoes not have to be a physician..

““Non-physician practitioners, e.g., nurse practitioners, Non-physician practitioners, e.g., nurse practitioners, certified nurse mid-wives or physician assistants, may….also certified nurse mid-wives or physician assistants, may….also perform other medically necessary services, e.g., perform other medically necessary services, e.g., consultations when the performance is within the scope of consultations when the performance is within the scope of practice for that type of non-physician practitioner in the practice for that type of non-physician practitioner in the State in which they practice. Applicable collaboration and State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules.” general supervision rules apply as well as billing rules.” [MCM [MCM §§15506 (C)]15506 (C)]

[CPT Assistant, January 2002, “Beyond the Ordinary: Coding [CPT Assistant, January 2002, “Beyond the Ordinary: Coding ‘Challenging’ E/M Circumstances,” Case #2 – “The fact that ‘Challenging’ E/M Circumstances,” Case #2 – “The fact that this is an established patient of the family practitioner is this is an established patient of the family practitioner is irrelevant.”] Medicare agrees [MCM irrelevant.”] Medicare agrees [MCM § § 15506 (E) and (F)].15506 (E) and (F)].

Unusual Consultation Unusual Consultation RequestsRequests Pre-surgical clearance from the PCP or specialist Pre-surgical clearance from the PCP or specialist

treating the condition.treating the condition. Intra-specialty consultation requests (e.g., a Intra-specialty consultation requests (e.g., a

gastroenterologist requests a consultation from a GI gastroenterologist requests a consultation from a GI motility specialist).motility specialist).[CPT Assistant, June 1999 and April 2000][CPT Assistant, June 1999 and April 2000]

Intra-specialty, intra-practice consultation requests Intra-specialty, intra-practice consultation requests (e.g., orthopedic surgeon requests consult from (e.g., orthopedic surgeon requests consult from his/her spine specialist partner. Or a pediatrician his/her spine specialist partner. Or a pediatrician requests a consult from his nurse practitioner who requests a consult from his nurse practitioner who has special training in diagnosis and treatment of has special training in diagnosis and treatment of children with ADHD).children with ADHD).[CPT Assistant, April 2000][CPT Assistant, April 2000]

Use of Modifiers with Use of Modifiers with Consultation ServicesConsultation Services

-25-25 “Significant, Separately Identifiable Evaluation “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on and Management Service by the Same Physician on the Same Day of the Procedure or other service. the Same Day of the Procedure or other service.

* If there are diagnostic or therapeutic services * If there are diagnostic or therapeutic services that were that were performed on the same day as the performed on the same day as the consultation evaluation.consultation evaluation.

-32-32 “Mandated Service”“Mandated Service”*Should be used when the evaluation is required *Should be used when the evaluation is required

by a third party payer.by a third party payer.-57-57 “Decision for Surgery”“Decision for Surgery”

* Most often used for emergency room and * Most often used for emergency room and inpatient inpatient consultations. consultations.

* Use if the decision to immediately perform * Use if the decision to immediately perform surgery was a result surgery was a result of the consultation evaluation.of the consultation evaluation.

Do’s and Don’ts of Do’s and Don’ts of Consultation BillingConsultation Billing

DODO DoDo check your state Medicaid and contracted check your state Medicaid and contracted

managed care program definitions for consultation managed care program definitions for consultation services, they may be different than CPT or services, they may be different than CPT or Medicare’s definitions.Medicare’s definitions.

DoDo document the request for advice or opinion in document the request for advice or opinion in your medical record and be as specific as possible.your medical record and be as specific as possible.

DoDo promptly return a written report to the promptly return a written report to the requesting physician with a copy of the report in requesting physician with a copy of the report in your records.your records.

DoDo charge for a consultation service when a surgeon charge for a consultation service when a surgeon asks you for surgical clearance.asks you for surgical clearance.

DoDo charge for consultation services when a medically charge for consultation services when a medically necessary opinion is sought from a physician of the necessary opinion is sought from a physician of the same specialty as the requesting physician.same specialty as the requesting physician.

Do’s and Don’ts of Do’s and Don’ts of Consultation BillingConsultation Billing

DON’TDON’T Don’t Don’t charge for a consultation when the patient charge for a consultation when the patient

comes to you for ER follow-up care.comes to you for ER follow-up care. Don’tDon’t charge for a consultation when the patient has charge for a consultation when the patient has

self referred to your practice.self referred to your practice. Don’tDon’t charge for a consultation when the patient charge for a consultation when the patient

received your name as just a recommendation from received your name as just a recommendation from another physician.another physician.

Don’tDon’t charge for a consultation every time a new charge for a consultation every time a new managed care referral form is received.managed care referral form is received.

Don’tDon’t forget to make sure that the documentation forget to make sure that the documentation supports all three “R’s.” If any one of the three are supports all three “R’s.” If any one of the three are missing, according to both CPT and Medicare, the missing, according to both CPT and Medicare, the service must be charged as a regular office or service must be charged as a regular office or hospital visit, regardless of the intent of the hospital visit, regardless of the intent of the requesting physician.requesting physician.

Consultation ChecklistConsultation Checklist Is this encounter a request for my advice or Is this encounter a request for my advice or

opinion?opinion? Is the request for consultation documented in my Is the request for consultation documented in my

copy of the medical record?copy of the medical record? Is the medical necessity for this service Is the medical necessity for this service

demonstrated and have I provided the key demonstrated and have I provided the key elements of E/M documentation to support the elements of E/M documentation to support the service that was billed?service that was billed?

Did the requesting physician or other appropriate Did the requesting physician or other appropriate source receive a written report and is there a source receive a written report and is there a copy of this report in my medical record?copy of this report in my medical record?

HISTORY QUESTIONNAIRE Date: Name: Last First Middle Patient ID number (office use only)

Birth Date Male Female

Chief Complaint (Reason for visit)

Date of Injury:

History of the Present Illness** Location (Identify specific location of the pain or problem) ______________________________________________________________ Quality (Has the pain increased or decreased since the injury or symptom happened) ______________________________________________________________ Severity (Identify on a scale of 1 to 10 the degree of pain) None - 1 2 3 4 5 6 7 8 9 10 - Severe Duration (Identify the length of time of the injury or symptom) ______________________________________________________________ Timing (Is there a time or condition that increases or decreases the pain) ______________________________________________________________ Context (How did the injury happen or when did the symptoms start) __________________________________________________________________ Modifying Factors (Do certain conditions increase or decrease the pain or problem) ______________________________________________________________________________________ Associated Signs & Symptoms (Has this injury or symptom created problems with other areas of the body) ______________________________________________________________________________________

Review of Systems** PRIMARY SYSTEMS

Do you now or have you ever had any problems related to the following systems? Please circle Y (Yes) or N (No) (Please explain any Yes answers in space provided or on attached sheet.)

Musculoskeletal Constitutional Symptoms Head and Neck Y N Fever/Temperature Y N Spine, Ribs, Pelvis Y N Weight gain/loss Y N Right Upper Extremity Arm Y N Headache Y N Left Upper Extremity Arm Y N Other _________________________ Right Lower Extremity Leg Y N Left Lower Extremity Leg Y N Integumentary Comments______________________ Skin rash Y N Skin Inflammation Y N Neurological Other_________________________ Tremors Y N Dizzy Spells Y N Hematologic/Lymphatic Numbness/Tingling Y N Swollen Glands Y N Other__________________________ Blood Clotting problem Y N Other____________________ Cardiovascular Chest Pain Y N Psychological Varicose Veins Y N Has this injury/condition affected your

attitude? Y N

High Blood Pressure Y N Other______________________

SECONDARY SYSTEMS Allergic/Immunologic Ear/Nose/Throat/Mouth Hay Fever Y N Ear Infections Y N Drug Allergies Y N Sore Throats Y N Food Allergies Y N Sinus Problems Y N Other__________________________ Other_________________________ Gastrointestinal Y N Eyes Abdominal Y N Blurred Vision Y N Nausea/Vomiting Y N Double Vision Y N Indigestion/Heartburn Y N Pain Y N Other__________________________ Other_________________________ Respiratory Endocrine Wheezing Y N Excessive Thirst Y N Frequent Cough Y N Too Hot/Cold Y N Shortness of Breath Y N Tired/Sluggish Y N Other__________________________ Other_____________________ Genitourinary Urine Retention Y N Painful Urination Y N Other__________________________

Past, Family & Social History**

Occupation: _________________________ Is this injury job related? Y N Were you referred by another Doctor? Y N If yes, who__________________________ List any personal past illnesses and/or surgeries and when they occurred. Illness or surgery Date Are you on any medications? Y N (Please identify) ____________________________________ __________________________________________ List all related injuries or conditions in your immediate family. Description Family Member ___________________________________ ___________________________________ Identify activities that have affected your injury or condition. Do you exercise regularly? Y N Do you participate in sports? Y N Does your job require physical exercise? Please explain.

Y N Are there other circumstances that affect this condition? Please explain.

Y N

First Visit:

Comments:

Physician:____________________ Date:__________ Subsequent Visits: Physician:____________________ Date:__________ Physician:____________________ Date:__________

HISTORY QUESTIONNAIRE

DATE NAME: Last First Middle M S W D Date of Birth Age Marital Status Male Female Employer Occupation Family MD Referring MD

Chief Complaint (Reason for visit, When did your symptoms start?)

If this is an injury, is it related to your employment?

History of the Present Illness** Latex Allergies: Yes No Allergies: Medication/Dose/Frequency

1. 5. 2. 6. 3. 7. 4. 8.

PLEASE USE ATTACHED SHEET IF EXTRA SPACE IS NECESSARY

Review of Systems** Do you now or have you ever had any problems related to the following systems? Please circle Y (Yes) or N (No) (Please explain any Yes answers in space provided or on attached sheet.)

Constitutional Symptoms Musculoskeletal Fever / Temperature Y N Head and Neck Y N Weight gain/loss Y N Spine, Ribs, Pelvis Y N Headache Y N Right Upper Extremity (arm) Y N Other Left Upper Extremity (arm) Y N Right Lower Extremity (leg) Y N Neurological Left Lower Extremity (leg) Y N Tremors Y N Comments Dizzy Spells Y N Numbness/Tingling Y N Integumentary Other Skin Rash Y N Inflammation Y N Psychological Other Has this injury/condition affected your attitude? Y N

Location (Identify specific location of the pain or problem) ______________________________________________________________ Quality (Has the pain increased or decreased since the injury or symptom happened) ______________________________________________________________ Severity (Identify on a scale of 1 to 10 the degree of pain) None - 1 2 3 4 5 6 7 8 9 10 - Severe Duration (Identify the length of time of the injury or symptom) ______________________________________________________________ Timing (Is there a time or condition that increases or decreases the pain) ______________________________________________________________ Context (How did the injury happen or when did the symptoms start) __________________________________________________________________ Modifying Factors (Do certain conditions increase or decrease the pain or problem) ___________________________________________________________________________________ Associated Signs & Symptoms (Has this injury or symptom created problems with other areas of the body)

Cardiovascular Hematologic/Lymphatic Chest Pain Y N Swollen Glands Y N Varicose Veins Y N Blood Clotting Problem Y N High Blood Pressure Y N Other Other Ear/Nose/Throat/Mouth Allergic/Immunologic Ear Infections Y N Hay Fever Y N Sore Throats Y N Drug Allergies Y N Sinus Problems Y N Other Other Gastrointestinal Eyes Abdominal Problems Y N Blurred Vision Y N Nausea/Vomiting Y N Double Vision Y N Indigestion/Heartburn Y N Pain Y N Other Respiratory

Wheezing Y N Endocrine Frequent Cough Y N Excessive Thirst Y N Shortness of Breath Y N Too Hot/Cold Y N Other Tired/Sluggish Y N Other Genitourinary Urine Retention Y N Painful Urination Y N Other

Past, Family & Social History** CIRCLE ANY OF THE FOLLOWING ILLNESSES YOU HAVE HAD: Circle Yes (Y) or No (N) Y N High Blood Pressure Y N Rheumatic Fever Y N Emphysema Y N Thyroid Trouble Y N Pneumonia Y N Diabetes Y N Yellow Jaundice

Y N HIV (AIDS) Y N Scarlet Fever Y N Tuberculosis Y N Kidney Infection Y N Transfusion with blood byproduct

Y N Heart Trouble Y N Ulcer Y N Asthma Y N Seizures Y N Unconsciousness Y N Head Injury Y N Fractures

Year of your last physical ______ Where? __________________________________________________ When did you have your last chest x-ray?________ Electrocardiogram? _________ Pap Smear? _______ Do you smoke? Y N Cigarettes per day_________ How many years have you Smoked?___________ When did you quit?__________________

Do you drink alcohol? Y N How many drinks do you consume per day? ______________________ Menstrual History: Last Period___________ Onset Age __________ Regular Periods? Y N Are you Pregnant? Y N No. of pregnancies?____ Age of first Pregnancy _________ No. of Children Other Medical Problems/Hospitalizations: Previous Surgeries: Alive Deceased Cause of

Death Alive Deceased Cause of

Death Mother Brothers Father Sisters Spouse Grandparents

ILLNESSES THAT OCCUR IN YOUR FAMILY: Cancer of the Bowel Y N Cancer of the Ovary/Uterus Y N Bleeding Y N Cancer of the Breast Y N Other Cancers:__________________ Diabetes Y N Cancer of the Lung Y N Severe or early age heart problems Y N High Blood Pressure Y N

Any problems after anesthesia Y N **(If additional space is needed in order to complete this questionnaire, please use the attached sheet.) Date:_____________ TEMP:_____ B/P:___________________ HT:_____________ WT:______________ Completed By:________________________ Physician Signature:___________________ Date___________

•Documentation of an encounter dominated by counseling or coordination of care.

• In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face in the office or other outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M service.

• If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

Time as the Main Component

TIME COMPONENTTIME COMPONENT

Code Time Code Time Code Time

99201 10 min 99211 5 min

99241 15 min

99202 20 min 99212 10 min

99242 30 min

99203 30 min 99213 15 min

99243 40 min

99204 45 min 99214 25 min

99244 60 min

99205 60 min 99215 40 min

99245 80 min

New New PatientPatient

EstablishEstablished Patiented Patient

OutpatienOutpatient Consultt Consult

Contact InformationGary Cavett, CPAPresident51 BroadwaySuite 601P.O. Box 2927Fargo, ND 58108

Tel: (701) 235-1124Fax: (701) 235-1854Email: [email protected] site: www.gmcavett.com

Documents

Developing an E&M Chart Review Process