American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to bill for consults, analyze use of E/M codes

From the February 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: I often see patients at the request of another physician. Should I use the consultation codes when billing for the services I provide to these patients?

A: First consider what constitutes a consultation. A consultation usually occurs when a physician requests the opinion or advice of another physician on the evaluation and/or management of a specific problem. (The person requesting the opinion or advice does not necessarily have to be a physician.) During a consultative visit, a physician:

  • offers an opinion or advice to the requesting physician;
  • makes a decision for treatment option(s); and
  • performs and/or orders distinctive diagnostic and/or therapeutic procedures.

    To bill for a consultation, you must:

  • document your advice or opinion;
  • document any services you performed or ordered; and
  • communicate this information back to the requesting physician.

This communication can be a letter sent back to the requesting physician, but it can also be a conversation if both you and the requesting physician document what you discuss. The physician who requests the opinion or advice must first document in the patient's chart the reason for requesting the consultation. If your encounter with a patient at the request of another physician meets these criteria, bill for a consultation.

In your documentation, identify the physician who asks for your opinion or advice as the "requesting" physician. Don't allude to the requesting physician as the "referring" physician; the term indicates a physician who has transferred a patient to another physician's care.

Q: My partner and I both want to compare our evaluation and management service billing patterns for our Medicare patients with the national averages. I am a general internist and he is an internist specializing in rheumatology. Is this information readily available?

A: HCFA maintains Medicare Part B billing data for physicians' services and makes 1997 specialty-specific procedure code utilization figures available through its home page on the Internet. HCFA's database allows you to view the number of times your specialty billed each Current Procedural Terminology (CPT) code. Using this information and a few simple calculations, you can determine the frequency with which your specialty billed Medicare for a particular CPT code within its family of codes.

Follow these instructions regarding how to use HCFA's online database to find out the frequency and distribution of your specialty's billing of specific CPT codes.

  • Create a folder on your C drive and name it "Specialty Utilization."
  • Go to HCFA's Internet home page at www.hcfa.gov.
  • Click on the "Stats and Data" box listed in the left hand column of the site's main page, which contains a "Welcome to HCFA" heading.
  • Click on "1999 Resource Based Practice Expense Data Files," which is the second bullet listed under the "Information Clearinghouse" heading.
  • Click on "Procedure Code Utilization by Specialty," which is the fifth option under the "1999 Interim Resource Based Practice Expense Data Files" heading.
  • You will be prompted to save the database file to your hard disk; click on the "yes" button and save the file in the "Specialty Utilization" folder you created on your C drive. Once the file has been saved, exit your Internet browser.
  • Go to your C drive and open the "Specialty Utilization" folder. You will find a file named Specutil.exe; double click on this folder. A DOS window will appear telling you that three files are being uncompressed and deposited into your "Specialty Utilization" folder. The DOS window will disappear once the files have been decompressed.
  • Go to your "Specialty Utilization" folder. In addition to the Specutil.exe file (which you can discard), there should be four other files. Look for the file named Specutil.mdb and open it in Microsoft Access or another database program. If you have a recent version of Access, you will be prompted to convert or open the file; choose to convert the file. You will then be prompted to save the file; save it in your "Specialty Utilization" and assign it a new file name.
  • A box will appear asking you to acknowledge the AMA's copyright; click on the "OK" button. In Microsoft Access, you will see three tables.

    1. A note on nonfacility PE-RVU; disregard this information.

    2. A specialty code description table; this file lists all the specialty designation codes. For example, the specialty designation code for internal medicine is "11" and the code for rheumatology is "66." You will use the two-digit number for your specialty to locate the relevant data in the utilization database.

    3. A utilization table; this table contains utilization data per code for each specialty. The table, which contains a massive amount of information, has headings of: CPT (HCPCS) code; modifier, HCFA specialty code; facility indicator; and allowed service.

  • Take the following steps to determine the frequency and distribution of billings for a family of codes:

    1. Select a family of codes.

    2. Find the appropriate specialty code and total the "allowed service" column for each individual CPT code. Note: A single specialty may have more than one allowed service number for a single CPT code because of modifiers.

    3. Add the allowed services for each CPT code to arrive at the total for the specialty for a family of codes.

    4. Divide the total allowed services for each individual CPT by the total allowed services for the family of codes to arrive at a percentage for each individual code. The percentage for each code signifies the frequency with which it is billed compared to the other levels of service within its family of codes.

By using these instructions, for instance, you can find the frequency and distribution of internists' billing of established patient office visit codes. (For an example, see the box on this page.)

You can use these figures, which represent national billing patterns, as a general guide when assessing your own billing patterns. Be warned, however: While Medicare carriers use physician billing profiles to determine when to initiate post-payment utilization-review audits, they typically look for aberrations by comparing a physician's billing pattern to the profiles of other physicians of the same specialty who practice in the same area.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to bbaker@acponline.org.

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