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Tips for Avoiding Medical Coding Conflicts with Consulting Physician

December 5, 2017

Avoiding Medical Coding Conflicts.jpg

In a number of specialty practices, such as internal or sports medicine, sooner or later a practitioner may find themselves participating as a consulting physician at the request of another provider. Whether functioning in an orthopedic capacity for x-ray readings, as in the case of a worsening condition, or an internist confirming pre-op surgery clearance, consulting can be tricky to properly code for reimbursement. Adhering closely to changing federal (CMS) and insurance industry guidelines while still providing the services and care required can be challenging; knowing which of the new ICD-10 codes and modifiers to use for accurate, reimbursable billing makes it more so.

Documentation is the key to reimbursement

There are two pieces of information that absolutely must be provided when billing for a consultation:

  • Consultant providers must document the request for the consult, such as “Patient seen in consultation at the request of Dr. (name) for: ____” indicating the reason’s context or problem.
  • If you don’t already have a shared patient medical record with the requesting provider, be sure that the findings are documented as having been shared with the requestor via fax, message or through a c.c.

Combining specialties and the ICD-10 effect

A family medicine practitioner who also works with a sports medicine consortium is asked by another provider to review images for a previously diagnosed injury, which can create a coding dilemma.  Sports medicine consultations often involve reviewing images, such as x-rays, as opposed to just reading a report or doing a procedure during a consulting visit, while an internal medicine practitioner’s consults may include reviewing lab work, EKG, or pre-op clearance.  
Use these two guideline examples when deciding whether to code as a 99243 vs. 99244:

  • On the sports medicine end, there may be a known previously-diagnosed problem, per the history of present illness (HPI) that is getting worse. If so, it should be made clear that additional intervention is needed. Example:a ‘stable’ along with a worsening problem indicates moderate medical Decision making (MDM) versus low (level 4 vs 3).
  • In pre-op consults, pay attention to the HPI which tends to be overlooked.If the patient has at least three additional chronic issues, documentation should give the status of these problems (medications, lab work, and so on) with the attending physician (AP) also documenting the same issues. It is necessary at this stage to indicate that the patient is low-to-moderate risk for surgery; if the patient has one or two stables then it’s most likely at level 3. Three or more documented risk factors raise it to a level 4.

Related Article: 3 Major Medical Coding Mistakes Providers Must Know

To further complicate things, in 2016, the American Medical Association (AMA) revised two CPT codes – 99354 and 99355 – describing prolonged evaluation and management (E&M) by physicians or other qualified health care professionals. Additionally, they created two new codes – 99415 – 99416 – to describe prolonged E&M services provided by clinical staff under supervision by a qualified provider.

The benefits of working with an experienced medical billing service

For physicians’ offices and other providers concerned with reviewing their Medicare documentation and coding procedures meeting the CMS as well as other federal and insurer requirements, partnering with an experienced claims services company such as M-Scribe can be one answer to consultant coding dilemmas.

M-Scribe has been helping practices of all sizes and specialties with coding and other medical documentation since 2002. Their experienced billing and coding personnel have access to the latest software and other technologies to ensure that claims are sent out accurately and on time, saving practices time and money while remaining compliant of federal and other regulations.  Contact M-Scribe today at 1-888-727-4234 or by email for a free consultation to analyze your practice’s needs and increasing revenue goals.


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