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Avoid Payment Pitfalls for Perioperative Consults


 

MIAMI BEACH — A hospitalist who is asked to perform a perioperative consultation can optimize reimbursement by getting the request in writing, making sure that it outlines a specific reason or concern, and documenting that a written report has been submitted.

Do not agree to evaluate a patient based only on a spoken request or in response to being paged within the hospital, advised Gail Pfeiffer, director of coding compliance at the Cleveland Clinic. “You need to nicely remind the doctor that you need a written order.

“The biggest challenge is getting back to those folks requesting your services and getting them to use the proper language,” Ms. Pfeiffer said at a meeting on perioperative medicine sponsored by the University of Miami.

The requesting physician must document the purpose of the consultation. “Our carrier really stressed that writing 'consult' is not enough. They need a reason,” Ms. Pfeiffer said. Terminology is important; words such as “consult,” “evaluation,” and “opinion” are good to include in a request, provided that they are supported with specifics. “If it appears to be a co-evaluation, the consultant is at higher medicolegal risk.”

A hospitalist also must document properly. “You have to document 'consult received for Dr. X for evaluation of Y.' You have to make a statement that you received that order,” she said.

Consultation codes are common sources of error, according to the Comprehensive Error Rate Testing (CERT) program. For example, in Ohio, CERT data revealed a 20% error rate for consultation codes.

Along with coding, proper supporting documentation is essential to optimize reimbursement. Documentation that supports a lower level of service or that lacks “the 3Rs” (a request in writing, a rendered opinion, and a report with recommendations) are the most common consultation errors, she said. “The more you can be explicit, the better,” Ms. Pfeiffer said.

Documentation may differ based on whether you work in a shared-record versus separate-record environment. Inpatient stays are almost always a shared-record situation. “I recommend a note in your record that states 'this record will be shared with requesting physician via e-mail, fax, or whatever,'” she said. In contrast, if the consultation request came from a physician outside your institution or health system, “you have to demonstrate in your record that you sent a report to the requesting physician.”

When requesting reimbursement for a preoperative consultation, for example, the first listed ICD-9 code should be V72.8x, Ms. Pfeiffer said. The preoperative diagnosis or reason for surgery dictates the second code, and the third through eighth codes identify comorbid and underlying conditions, as well as appropriate personal and family history codes. Keep in mind that some payers recognize only the first four codes, so it is important to prioritize, she advised.

“Most payers will pay for preoperative consultations as long as you meet all the requirements,” she said. “Medicare will pay as long as it is medically necessary—in other words, [it is] not routine screening.” If you are concerned that a payer might consider the consultation routine, cite a patient's comorbid conditions, risk factors, and chronic medication use. “Most of the patients you see I would think have underlying conditions.”

Medicare does not consider a postoperative evaluation a consultation if you or someone in your group performed the preoperative consultation on the same patient. “It's follow-up care for that same visit,” she said. Instead, use subsequent coding when the same patient is seen again postoperatively.

A meeting attendee asked how to bill when a consultation service is split between a physician and a midlevel provider. Most payers “don't want you to split the consult at all,” Ms. Pfeiffer replied. “We tend not to use midlevels to do consults.”