Consult vs referral

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A consult is when you are referred a patient and you send them back to the referring doctor with recommendations for treatment. You don't do any treatment - all the referring doc wants is advice. I never get these. The only time I code for a consult is if I don't plan to see the patient after that visit. Usually that's a case where there are warning signs of a difficult patient - multiple pain clinics, drug-seeker, h/o noncompliance, etc) and I want to lay an eyeball on them before deciding if I'll treat them.

If you plan to treat the patient (99+% of my new patients) use the New Outpatient Visit codes. The vast majority of your referrals will probably be New Outpatient Visit codes.

Billing a lot of consult codes instead of new patient codes is a sure way to make Medicare notice you.
 
gorback said:
The only time I code for a consult is if I don't plan to see the patient after that visit. Usually that's a case where there are warning signs of a difficult patient - multiple pain clinics, drug-seeker, h/o noncompliance, etc) and I want to lay an eyeball on them before deciding if I'll treat them.
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I do this as well.

In your experience how often does this piss off the refering doc? i.e. the PCP who started the patient (with significant Psyche or substance abuse history)on Oxy, Percocet, Xanax, etc., it didn't work, and now wants you to take over.

The other day I got a referral from a PCP (who refers us patients for epidurals) to treat a patient's pain that was secondary to his skin abcesses/phlebitis from active heroin abuse.

In the past I've "consulted" on patients and recommended a psyche eval, etc., only to have the referring doc call me the next day, with the patient in sitting in their office, pressuring me to prescribe something.
 
If it's a good referral source sometimes you just have to take a bullet now and then.

Narcotics are not for everyone. It is perfectly legitimate to make the patient an offer such as "any type of pain management they want except for narcotics" or offer only suboxone or methadone for analgesia. If they refuse, THEY rejected YOU, which I usually find preferable.

In any case, if things don't work out call the referring doc the minute the patient leaves, because they are going to call that doc from their car and trash you. You need to register your side of the story first.

The referring docs usually know what they have sent you so they aren't surprised at the outcome of the referral. Chances are they are sick of dealing with the patient themselves. I have never had a referring doc call me to pressure me to prescribe. I guess if they did I'd explain why I won't.

Sometimes the PCPs dig themselves a hole with pain meds and expect us to fill it in. That in itself is not a sin, but if the patient needs detox then they are in the wrong office.

Here's how I deal with the "drugs vs other treatment" issue. I tell the patients my criteria for opioid prescribing:

1. An acute pain problem that is expected to be self-limiting (sprained ankle, postop pain, etc).

2. A persistent pain problem that requires analgesics for comfort while the patient awaits tests and/or procedures and/or other types of treatment (psych, PT, etc). Lumbar radiculopathy is a good example.

3. A persistent pain problem that has been refractory to everything we can reasonably try. Perhaps a CRPS patient has failed to thrive with PT, blocks, co-analgesics, SCS, etc. Time to revert to chronic opioids, with or without a pump.

4. A patient with persistent pain whose supervening medical conditions preclude other types of treatment. The typical example is a patient with a fresh coronary artery stent. Or perhaps chronic thrombocytopenia precludes consideration of blocks, a pump, or a stim.

If they don't fit into these criteria they don't get meds. This might happen in the middle of treatment, not just the beginning. For example, a patient who has some persistent pain after LESI and they want meds but refuse PT. They just fell out of category #2.

I tell them they have the right to refuse any treatment offered but that I have the right to refuse to participate in a treatment plan that I disagree with. They usually ask me where they will find someone who will prescribe them the drugs they want, and I tell them they need to look for a doctor who shares their treatment philosophy. If they can't find a doctor who shares their point of view maybe they need to change their point of view.
 
If the referral is from a doc from a different specialty (vast majority) and you have not seen them in 3 years, you can therefore code a consult unless you plan to follow them..however, wording such as "if the patient needs future evaluation, would be happy to see them back" should work...
 
gorback said:
If it's a good referral source sometimes you just have to take a bullet now and then.

Narcotics are not for everyone. It is perfectly legitimate to make the patient an offer such as "any type of pain management they want except for narcotics" or offer only suboxone or methadone for analgesia. If they refuse, THEY rejected YOU, which I usually find preferable.

In any case, if things don't work out call the referring doc the minute the patient leaves, because they are going to call that doc from their car and trash you. You need to register your side of the story first.

The referring docs usually know what they have sent you so they aren't surprised at the outcome of the referral. Chances are they are sick of dealing with the patient themselves. I have never had a referring doc call me to pressure me to prescribe. I guess if they did I'd explain why I won't.

Sometimes the PCPs dig themselves a hole with pain meds and expect us to fill it in. That in itself is not a sin, but if the patient needs detox then they are in the wrong office.

Here's how I deal with the "drugs vs other treatment" issue. I tell the patients my criteria for opioid prescribing:

1. An acute pain problem that is expected to be self-limiting (sprained ankle, postop pain, etc).

2. A persistent pain problem that requires analgesics for comfort while the patient awaits tests and/or procedures and/or other types of treatment (psych, PT, etc). Lumbar radiculopathy is a good example.

3. A persistent pain problem that has been refractory to everything we can reasonably try. Perhaps a CRPS patient has failed to thrive with PT, blocks, co-analgesics, SCS, etc. Time to revert to chronic opioids, with or without a pump.

4. A patient with persistent pain whose supervening medical conditions preclude other types of treatment. The typical example is a patient with a fresh coronary artery stent. Or perhaps chronic thrombocytopenia precludes consideration of blocks, a pump, or a stim.

If they don't fit into these criteria they don't get meds. This might happen in the middle of treatment, not just the beginning. For example, a patient who has some persistent pain after LESI and they want meds but refuse PT. They just fell out of category #2.

I tell them they have the right to refuse any treatment offered but that I have the right to refuse to participate in a treatment plan that I disagree with. They usually ask me where they will find someone who will prescribe them the drugs they want, and I tell them they need to look for a doctor who shares their treatment philosophy. If they can't find a doctor who shares their point of view maybe they need to change their point of view.
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Thanks,

That was very helpful.

The patient with the heroin problem (the PCP wanted me to take over Methadone prescriptions), I wrote in consult that he was not a candidate for opioids and that he needed a detox program. I then stated that I would have our staff look for a conveniently located detox program for the patient. Hopefully the PCP will appreciate the effort.
 
If the PCP is writing methadone to treat the heroin addiction, he is in violation of the controlled substances act, and can lose his DEA license. The PCP may need to have this information imparted to him. Methadone, for the treatment of heroin addiction, requires a special DEA methadone license that is usually given only to addictionologists in drug rehab centers.
 
algosdoc said:
If the PCP is writing methadone to treat the heroin addiction, he is in violation of the controlled substances act, and can lose his DEA license. The PCP may need to have this information imparted to him. Methadone, for the treatment of heroin addiction, requires a special DEA methadone license that is usually given only to addictionologists in drug rehab centers.
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you would be surprised how many PCP's do not know this or expect that you can do it as a pain management doctor...........
 
member said:
How do you clssify a new pt visit as consult or referral
thanks
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member you have asked a very good question. it is a point of confusion and contention. this is an except from the AMA that I would like you to read....i will give my own comments following this



Understanding consultations By Teresa Thompson, CPC, CMSCS, CCC In 2006, the Centers for Medicare & Medicaid Services (CMS) revised their definition of a consultation. Now in 2007, the issue has become more confusing since the 2007 CPT book has not adopted the CMS definition of “consultations” with the same specific language. Let’s review the definitions: A consultation is provided when the following criteria are met: 1. A request has been made for a physician’s opinion and advice concerning a specific problem from an appropriate source. The appropriate source may be another physician, nurse practitioner, physician assistant, chiropractor, physical therapist, occupational therapist, speech pathologist, psychologist, social worker, lawyer or insurance company. 2. The request for the opinion is documented in the patient’s chart. The consulting physician may initiate diagnostic or therapeutic services at the time of the consultation or at a subsequent visit. 3. The opinion of the physician who has been requested to provide the consultation must be documented in the patient’s chart, and the opinion must also be communicated to the requested physician in a written format. 4. After the consultation is completed and the physician who provided the consultation assumes management of the patient’s condition, the follow-up services are considered established patient encounters, and not consultations. The place of service will dictate which specific codes are to be used for the established patient encounter. CMS, in its manual dated December 20, 2005, (30.6.10 Consultations Revision 788) and implemented January 17, 2006, uses more specific guidelines to define a consultation. The differences between the 2007 CPT book and CMS are as follows: 1. A consultation may be requested not only of a physician but also of a non-physician practitioner, as long as their opinion or advice regarding a specific problem is requested by another physician or appropriate source. (CMS does not define appropriate source, but you will need an NPI number of the requesting provider to submit your claim to CMS.) 2. A consultation shall not be performed as a split/shared E/M visit. 3. Payment for consultations shall be made unless a “transfer of care” occurs. • CMS defines a transfer of care: “When a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition, and does not expect to continue treating or caring for the patient for that condition. When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is
not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care to his/her service in the patient’s medical record or plan of care. In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed, and shall not report a consultation service.” This definition of “transfer of care” by CMS is different than what has been practiced in the past. In the past, a “transfer of care” meant the complete care of the patient. Allergists will want to make note if they are charging for consultations, and the carrier is either Medicare/Medicaid or follows Medicare guidelines, that they do not “assume care” of the patient for their allergies and asthma. If the intent of the allergist is to “co-manage” with the PCP or other physician, it would be wise for the allergist to make sure that this is documented in the patient’s chart, and that all of the criteria (request documented, opinion documented and a written report is sent back) are met for the consultation. CMS initially indicated that the consultant was accountable for the physician’s documentation requesting the consult. This guideline has been relaxed and consultants are only responsible for their documentation of the request of the consultation in their chart. You may want to indicate in the body of your note who asked for the consultation. Don’t leave it up to your staff to document this important information, since many times when a chart note is sent, no supporting documentation is sent with the chart note to indicate who has requested the consultation. Consultations may be provided to new or established patients as long as the allergist has not been treating the patient for the specific problem. A consultation may also be charged when a surgeon asked for an opinion regarding the patient’s condition prior to surgery. If after the surgery, the allergist assumes management of their respiratory problems, then a subsequent hospital visit should be charged (99231-99233). As we progress through 2007, we may find that CMS either revises their definition or that in 2008 the CPT definition will be reflective of the current CMS definition. The most important guideline is that each practice should research what the individual carrier has adopted as a guideline for consultations, and have the guideline in your office on file. CPT © 2007 American Medical Association. All rights reserved.
 
First of all, I want to start out by saying that I am not a self proclaimed expert of E&M coding. However, when I first set up my practice, I paid mucho dinero to bring in a pain management coding specialist (yes these people do exist). She spent 3.5 days one on one with my practice and my office manager (i was not as busy at the time so this did not hurt my practice). She looked at my coding pattern and felt that it was correct.


I disagree with a few things that gorback and disciple said. First of all if you read the rules from medicare and AMA in my previous post, you can see that a consult may be coded even if you are providing ongoing care (ie epidural steroids, etc.). It really comes down to the intent of the referring physician. I would argue that any patient referred to you for long term opioid management is a referral and not a consult even if you only see the patient one time. It is usually the intention of the referring doctor to ask you to completely take over their care in this case. This is especially true if the referral comes from another pain management specialist. These should be coded as 99202 to 99205. This is true of the patients that both gorback and disciple described in their posts. In most instances for injections, the referring doctor IS asking for your opinion and thus a 99242-99245 code is acceptable. Most physicians do not realize how much money they are costing their practice by undercoding. The million dollar question is "Will this survive an audit?". I dont know the answer to this. My pain coding consultant seemed to think so. I am interested in other opinions. Many times the referring doctor sends a a referral note asking for a consult. This would further strengthen your defense. I just dont agree with downcoding to avoid an audit....


If you are really interested, contact one of the pain management coding experts. I used Joanne Mehmert who is a well known national expert in pain management coding (i am sure that many of you will probably recognize her name). She is not cheap but she left us with a lot of knowledge..... If you read the previous post from the AMA, you will see that it is not clear cut and can be left for a lot of interpretation. I am interested in other opinions...Member, this was an excellent question.
 
This is a rather unique interpretation of the definition since it requires the receiving physician to be a mind reader. Although there is a lot of language there about the intent of the referring physician, the key principle is "transfer of care". The referring doctor may intend for you to accept the transfer of care, but it does not actually occur until you accept the transfer.

It would be interesting to see a panel of coding experts argue this issue, where the referring doctor intends a transfer of care but the receiving doctor refuses. I'll bet we get differing opinions.
 
Thank you all for your input. I appreciate it.
 
Would you consider a Neurosurgical, Orthopeadic, Pain Physician, or PCP referral for an "epidural or interventional injection" a consult?

Assume they have filled out a prescription for a "consult" and on their clinical notes they expect the patient to "return for follow up 3wks post injection."

It may turn out that you take over the medications or even modify them.
Ultimately you are being consulted and providing a treatment. I don't always assume that most physcians are trying to "transfer care" or dump their patients, it just happens over time...

Every case is unique. In a complex case with many pain generators, I usually bill a New pt comprehensive.
 
stim4u said:
Would you consider a Neurosurgical, Orthopeadic, Pain Physician, or PCP referral for an "epidural or interventional injection" a consult?

Assume they have filled out a prescription for a "consult" and on their clinical notes they expect the patient to "return for follow up 3wks post injection."

It may turn out that you take over the medications or even modify them.
Ultimately you are being consulted and providing a treatment. I don't always assume that most physcians are trying to "transfer care" or dump their patients, it just happens over time...

Every case is unique. In a complex case with many pain generators, I usually bill a New pt comprehensive.
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i would bill your case as a consult (99242 to 99245)....i feel that you would have evidence in the chart to support this coding.....i am interested to hear the thoughts of others...........
 
The old definition of transfer of care meant total transfer. However, now it can mean transfer of just one aspect. If I refer a patient for management of diabetes that is a transfer of care, but I am still treating the patient for pain.

These are interesting questions. If you get a referral for an ESI and decide to do an ESI, that is probably not a consult but a transfer of care. However, what happens if you see the patient and decide not to treat them?

I don't think they were considering weirdo specialties like pain management when they came up with these rules. We therefore need new codes for pain management evaluations:

99271 - referral for prescription writing
99272 - referral for total body pain
99273 - referral for postop orthopedic patient who keeps asking for more Vicodin

or 99666, the one I got today - chronic kidney stones and no one willing to continue writing for Vicodin.

Some days you're the anteater, some days you're the ant.
 
Right or wrong, the method I've adopted for the time being is as follows:

1. Patient referred on few meds, MRIs already done, it says LESI on the referral script (occasionally a stim trial is requested)--generally billed as consult and returned to the PCP after injection

2. Complex pain problem (notes indicate increasing meds over a period of time, then "refer to pain management")--billed as new patient.

3. Same type of patient as #2, recommendations made but not accepted into the practice--billed as consult.
 
Disciple said:
Right or wrong, the method I've adopted for the time being is as follows:

1. Patient referred on few meds, MRIs already done, it says LESI on the referral script (occasionally a stim trial is requested)--generally billed as consult and returned to the PCP after injection

2. Complex pain problem (notes indicate increasing meds over a period of time, then "refer to pain management"--billed as new patient.

3. Same type of patient as #2, recommendations made but not accepted into the practice--billed as consult.
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i dont think that the "rules" support number 3 being billed as a consult (but that is just my interpretation). The "rules" however are very vague and you may be able to defend it if audited.
 
When in doubt use the "new patient" code. You will not get into trouble for using that instead of the consult code (they don't mind if you under-bill), but not vice-versa. Actually I doubt an occasional miscoded consult will cause you any grief. It's the people who bill the consult code for every new patient that show up on the radar.

I almost never use the consult code because (1) without exception my referrals are for management (i.e., transfer of care), and (2) The difference in the fee is not that big, and you will sleep better. You lose more money than that in loose change when you take a nap on the couch.
 
Disciple said:
Thanks,

That was very helpful.

The patient with the heroin problem (the PCP wanted me to take over Methadone prescriptions), I wrote in consult that he was not a candidate for opioids and that he needed a detox program. I then stated that I would have our staff look for a conveniently located detox program for the patient. Hopefully the PCP will appreciate the effort.
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Had another one the other day. Patient with long history of migraines referred for opiate management. Come to find out he was also referred to a Neurologist who is still treating him (diagnosed hem with Greater Occipital Neuralgia-I concur) and a Psychiatrist for his significant anxiety and depression. He was referred to our practice to continue the Avinza (at least he was switched off of Oxy), Diaudid, Soma and Ativan.

After reviewing referal notes and examining him, find that he also has C2/3 facet and maybe anterior joint pain from several past MVAs. I D/C Ativan, Soma and Dilaudid, increase Avinza and recommend C2/3 facet/OA/AA injections and depending on the response, a trial of GON stim. Patient argues for about 5 minutes, then takes the prescription and leaves.

I don't think this one's coming back either.
 
Disciple said:
Had another one the other day. Patient with long history of migraines referred fo opiate management. Come to find out he was also referred to a Neurologist who is still treating her (diagnosed her with Greater Occipital Neuralgia-I concur) and a Psychiatrist for his significant anxiety and depression. He was referred to our practice to continue the Avinza (at least she was switched off of Oxy), Diaudid, Soma and Ativan.

After reviewing referal notes find that he also has C2/3 facet and maybe anterior joint pain from several past MVAs. I D/C Ativan, Soma and Dilaudid, increase Avinza and recommend C2/3 facet/OA/AA injections and depending on the response, a trial of GON stim. Patient argues for about 5 minutes, then takes the prescription and leaves.

I don't think this one's coming back either.
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write her a discharge letter.....you have nothing to gain by keeping noncompliant patients in your practice.
 
mille125 said:
write her a discharge letter.....you have nothing to gain by keeping noncompliant patients in your practice.
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Depending on the referral source, document in her chart her glaring wish to be noncompliant, her drug seeking behavior, and do not discharger her. She will not return unless she agrees with your care plan as you will not set up an appointment for her to just get the drugs she wants. Now in all the docs eyes she is the one causing problems and the care can get sifted more towards the psychiatrist who can decide if he wants her on BZD, Opioids, the meprobamate precursor, etc. If she wants help, you'll see her for procedures because she has allowed you to document the A's and C's.
 
99% of my visits are coded as consults

1) i require that every physician refer them to me for consultation
2) any patient who i see who hasn't been referred is coded as new patient instead of consult
3) i send a report back to the patient with my impression and recommendations...

i also made it clear to the community docs that i don't prescribe narcotics so therefore there is no need for "transfer of care"... the ones who still send me their narcotic patients i tell them that further narcotics are inappropriate in my opinion and recommend a wean - don't get many of those referrals anymore...

the CMS has made clear what constitutes a consultation and I can document everything in my chart (the letter the referring physician sent over to me, the letter back, etc...)
 
Why is writing a prescription a transfer of care but doing an injection is not? A consult is when you send the patient back with treatment recommendations for the referring doctor to follow. Seems to me if you treat the patient - no matter the modality - you have transferred care. I hope the OIG doesn't read this forum.
 
i also made it clear to the community docs that i don't prescribe narcotics so therefore there is no need for "transfer of care"... the ones who still send me their narcotic patients i tell them that further narcotics are inappropriate in my opinion and recommend a wean - don't get many of those referrals anymore.../
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I agree with Gorback. Also, why wouldn't you prescribe opioids? Do you REALLY believe they have no place in a comprehensive pain management practice?😕
 
Tenesma said:
99% of my visits are coded as consults

1) i require that every physician refer them to me for consultation
2) any patient who i see who hasn't been referred is coded as new patient instead of consult
3) i send a report back to the patient with my impression and recommendations...

i also made it clear to the community docs that i don't prescribe narcotics so therefore there is no need for "transfer of care"... the ones who still send me their narcotic patients i tell them that further narcotics are inappropriate in my opinion and recommend a wean - don't get many of those referrals anymore...

the CMS has made clear what constitutes a consultation and I can document everything in my chart (the letter the referring physician sent over to me, the letter back, etc...)
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i agree with you on the coding for consults....but the no opioids attitude??? (come on). I will say that if I were a community PCP in your practice area, I would not refer you one patient with that attitude... There is a place for chronic opioids and your referring physicians are looking for you to make recommendations. You are really letting them down and this is too bad. If you take the lead and help the PCP's discover who is an appropriate candidate for a trial of opioids, you will find that you new consults will soon be more appropriate. Your current stance is letting your community down. You should reconsider.
 
1) show me data that chronic opioids improve pain scores or outcomes (you cannot include cancer data nor can you include any short-term studies <12 months)

2) now look at all the data on long-term use of opioids - none of it is about functional improvement, it is all about side-effects, complications, etc...

3) PCPs prescribe narcotics on their own - why is it my responsibility to take over they faulty decisions?

4) if the patient is using the narcotic appropriately and showing good maintenance then the PCP isn't going to send that patient - they are only going to send the patients that in my opinion should never have even been started on those narcotics and now the PCP is in a bind. they send those patients to me - i evaluate them and send back my recommendations with a wean.... the PCPs LOVE THIS because it gives them an official out from a situation they dug themselves into... best example i can think of are the alcoholics who are abusing their vicodin...

5) i prescribe narcotics when i think it is appropriate (primarily nociceptive pain) and if there is evidence of functional improvement and improved pain score - which is about 2% of all consults....

6) i am in a semi-competitive market and I get 11-14 referrals per day and see between 6-9 new patients per day (5 days a week)... surprisingly more and more of those referrals are strictly for interventional approaches and less and less are for narcotics...

talk about a self-fulfilling prophecy...

there is this misconception that to make PCPs happy you have to take their scum.... well guess what? if you do a good job and build a reputation of offering primarily interventional approaches to pain, then those are the consults you are going to get.... the PCPs are smarter than you think and will find another pain dr to dump the narcotics on... which is what has happened to the pain clinics around me....

by the way i challenge you to show me the data - because if you find convincing data I may change my practice to reflect that...
 
I don't think interventional pain doctors really want to play the "show me the data" game. It's the Achilles heel of the entire specialty on much of what we do.

I guess since you don't believe in the effectiveness of chronic opioid therapy you don't do pumps.

"Scum"? That's what you call people who need pain medication?
 
Tenesma said:
1) show me data that chronic opioids improve pain scores or outcomes (you cannot include cancer data nor can you include any short-term studies <12 months)

2) now look at all the data on long-term use of opioids - none of it is about functional improvement, it is all about side-effects, complications, etc...

3) PCPs prescribe narcotics on their own - why is it my responsibility to take over they faulty decisions?

4) if the patient is using the narcotic appropriately and showing good maintenance then the PCP isn't going to send that patient - they are only going to send the patients that in my opinion should never have even been started on those narcotics and now the PCP is in a bind. they send those patients to me - i evaluate them and send back my recommendations with a wean.... the PCPs LOVE THIS because it gives them an official out from a situation they dug themselves into... best example i can think of are the alcoholics who are abusing their vicodin...

5) i prescribe narcotics when i think it is appropriate (primarily nociceptive pain) and if there is evidence of functional improvement and improved pain score - which is about 2% of all consults....

6) i am in a semi-competitive market and I get 11-14 referrals per day and see between 6-9 new patients per day (5 days a week)... surprisingly more and more of those referrals are strictly for interventional approaches and less and less are for narcotics...

talk about a self-fulfilling prophecy...

there is this misconception that to make PCPs happy you have to take their scum.... well guess what? if you do a good job and build a reputation of offering primarily interventional approaches to pain, then those are the consults you are going to get.... the PCPs are smarter than you think and will find another pain dr to dump the narcotics on... which is what has happened to the pain clinics around me....

by the way i challenge you to show me the data - because if you find convincing data I may change my practice to reflect that...
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I agree with Gorback. I have the following things to add (you are again giving me tenesmus):

1) You seem to contradict yourself in your last few posts. First you say that you tell PCP's that you do not prescribe any narcotics. Then, you say that you prescribe it to 2% of your patients. I think that even you would agree that these two statements are mutally exclusive.

2) You say that the reason that you do not prescribe narcotics as they there are no studies to document efficacy after 12 months or in nonmalignant pain. No, there are not any studies. But dont pretend that this is the reason that you are not prescribing opioids. There are no good studies that show that epidurals are effective after 12 months but I bet you perform many of these procedures. Give me a break......You need to use your own clinical experience sometime. I am sure that you have a few if not many patients who are able to keep a job or improve their function on opioids. You should know that double blinded, randomized control studies are difficult to perform in interventional pain management. I do not feel that you should continue opioid treatment in patients who are showing no progression in treatment or improvement in function. However, to wash your hands of all patients on opioids is irresponsible and a let down to your community (as you are supposed to be the expert).

In short I feel that you need to get out of the business. I know that this is a strong statement but this is how I feel. The real reason that you dont want to prescribe opioids is that either you want to make more money by doing procedures or that you have a lack of education about the drugs. If you were not taught about appropriate opioid management in fellowship then your preceptors failed you. I feel sorry for your patients and their referring providers. Lastly your "scum" comment is demeaning and insensitive.
 
mille125 said:
I agree with Gorback. I have the following things to add (you are again giving me tenesmus):

1) You seem to contradict yourself in your last few posts. First you say that you tell PCP's that you do not prescribe any narcotics. Then, you say that you prescribe it to 2% of your patients. I think that even you would agree that these two statements are mutally exclusive.

2) You say that the reason that you do not prescribe narcotics as they there are no studies to document efficacy after 12 months or in nonmalignant pain. No, there are not any studies. But dont pretend that this is the reason that you are not prescribing opioids. There are no good studies that show that epidurals are effective after 12 months but I bet you perform many of these procedures. Give me a break......You need to use your own clinical experience sometime. I am sure that you have a few if not many patients who are able to keep a job or improve their function on opioids. You should know that double blinded, randomized control studies are difficult to perform in interventional pain management. I do not feel that you should continue opioid treatment in patients who are showing no progression in treatment or improvement in function. However, to wash your hands of all patients on opioids is irresponsible and a let down to your community (as you are supposed to be the expert).

In short I feel that you need to get out of the business. I know that this is a strong statement but this is how I feel. The real reason that you dont want to prescribe opioids is that either you want to make more money by doing procedures or that you have a lack of education about the drugs. If you were not taught about appropriate opioid management in fellowship then your preceptors failed you. I feel sorry for your patients and their referring providers. Lastly your "scum" comment is demeaning and insensitive.
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I have to agree. Actually, I don't think Tenesma did a fellowship, but that's no excuse. His community considers him the "expert" and he is really letting them down.
 
sorry about the delay in getting back...

1) i did a fellowship and am sub-specialty board certified in pain - and my faculty are top-notch authorities on narcotics (one of them has a 7 PHD lab dedicated to the study of narcotics).... in fact i recommend some reading on opioid-induced hyperalgesia as this is a growing concern...

2) i mis-spoke i don't physically prescribe the narcotics - i recommend prescription of narcotics in about 2% of consults I see. Patients who demonstrate functional improvement on them without ANY red flags and who have organic disease that isn't responsive to other modalities

3) prescribing narcotics - i don't prescribe or recommend prescribing them for most patients for 2 reasons - lack of evidence showing improvement in outcome AND massive evidence of societal impact, long-term side-effects, etc...

4) i have chosen to focus my work on the interventional non-narcotic approach to back pain - just like electrophysiologists primarily do pacemakers and AICDs....

5) money: procedures are good money, but I have a few friends in florida who make more money than I do and they are 100% pharmacologic management... so if you have a good head for business, and are efficient you can make a good living no matter what... the key is to minimize overhead in the safest ways possible..

6) epidurals: there are no studies to show that epidurals are good for long-term control - in fact most studies suggest that at best they are helpful for short-term control and according to some studies even that is a stretch... Outcomes and Side-effects between epidurals and opiates cannot be compared --- you can't compare oranges to apples

7) getting out of business? well maybe that is what the pain clinics around me are hoping for.... but the feedback I get from the PCPs has been good (they love the fact that I don't prescribe narcotics - in fact, they are pissed off with the amount of narcotics that are coming out of surrounding pain clinics).... and the feedback I get from MOST of the patients I see has been good... they will frequently tell me that their pain score is unchanged despite being weaned off the narcotics, but at least they can have sexual desire again and don't have to deal with the constipation.... the patients who aren't happy with my recommendations have the following "red flags" and thus fall into my "scum" category 1) full disability but they can't remember why they are on disability 2) history of doctor shopping to get vicodin/soma 3) unwilling to consider any alternative pharmacologic treatments 4) non-compliant with most treatment recommendations 5) no clearly delineated organic disease - and 6) hx of drug abuse or active alcoholism....

--- now if your experience is vastly different from mine, and you find that most of your patients do very well on narcotic regimens, then please let me know which criteria you use and what drug combos work the best because it would be an extra feather in my cap if I could help more patients...
 
Tenesma said:
sorry about the delay in getting back...

1) i did a fellowship and am sub-specialty board certified in pain - and my faculty are top-notch authorities on narcotics (one of them has a 7 PHD lab dedicated to the study of narcotics).... in fact i recommend some reading on opioid-induced hyperalgesia as this is a growing concern...

2) i mis-spoke i don't physically prescribe the narcotics - i recommend prescription of narcotics in about 2% of consults I see. Patients who demonstrate functional improvement on them without ANY red flags and who have organic disease that isn't responsive to other modalities

3) prescribing narcotics - i don't prescribe or recommend prescribing them for most patients for 2 reasons - lack of evidence showing improvement in outcome AND massive evidence of societal impact, long-term side-effects, etc...

4) i have chosen to focus my work on the interventional non-narcotic approach to back pain - just like electrophysiologists primarily do pacemakers and AICDs....

5) money: procedures are good money, but I have a few friends in florida who make more money than I do and they are 100% pharmacologic management... so if you have a good head for business, and are efficient you can make a good living no matter what... the key is to minimize overhead in the safest ways possible..

6) epidurals: there are no studies to show that epidurals are good for long-term control - in fact most studies suggest that at best they are helpful for short-term control and according to some studies even that is a stretch... Outcomes and Side-effects between epidurals and opiates cannot be compared --- you can't compare oranges to apples

7) getting out of business? well maybe that is what the pain clinics around me are hoping for.... but the feedback I get from the PCPs has been good (they love the fact that I don't prescribe narcotics - in fact, they are pissed off with the amount of narcotics that are coming out of surrounding pain clinics).... and the feedback I get from MOST of the patients I see has been good... they will frequently tell me that their pain score is unchanged despite being weaned off the narcotics, but at least they can have sexual desire again and don't have to deal with the constipation.... the patients who aren't happy with my recommendations have the following "red flags" and thus fall into my "scum" category 1) full disability but they can't remember why they are on disability 2) history of doctor shopping to get vicodin/soma 3) unwilling to consider any alternative pharmacologic treatments 4) non-compliant with most treatment recommendations 5) no clearly delineated organic disease - and 6) hx of drug abuse or active alcoholism....

--- now if your experience is vastly different from mine, and you find that most of your patients do very well on narcotic regimens, then please let me know which criteria you use and what drug combos work the best because it would be an extra feather in my cap if I could help more patients...
Click to expand...



1) Opioid induced hyperalgesia is a real problem for several patients. I do not feel that you should continue to prescribe narcotics to these patients. I, fact, I recommend tapering. However, there are many patients who are on an appropriate dosage of long acting opioids and have an improvement in their function. I know of a few who now have a steady job and have become a productive part of our society. To withhold medication from these patients is not excusable. If in doubt give them a six month trial and then decide.

2) I know that opioids and epidurals are two different procedures with different indications and risks. However, you said that one of main reasons that you do not prescribe opioids is because of lack of efficacy in studies. I do not have a problem with that. However, with applying the same principles you should also not be involved in many interventional procedures including epidurals. This is my point. You also need to remember that epidural steroid and other pain procedures are not without risk and can cause catastrophic complications in a few cases.
 
This is a fascinating debate that strikes at the heart of the conflict within the pain community. There are champions on either side of this debate. Although this issue has been debated before, it seems that we should open this up an a new thread instead of taking a tangent away from the consult vs referral debate.

I will start us off with the new thread.
 
Hey don't start a flare in here on this subject it really isn't worth it !
 
gorback said:
This is a rather unique interpretation of the definition since it requires the receiving physician to be a mind reader. Although there is a lot of language there about the intent of the referring physician, the key principle is "transfer of care". The referring doctor may intend for you to accept the transfer of care, but it does not actually occur until you accept the transfer.

It would be interesting to see a panel of coding experts argue this issue, where the referring doctor intends a transfer of care but the receiving doctor refuses. I'll bet we get differing opinions.
Click to expand...

You have completely hit the nail on the head about the mind reading. I have talked to 3 different coding "experts" and they gave me 3 different answers. So I went to the AMA and Medicare guidelines and read them myself, like Mille125. Check out all the self contradiction in the guidelines- it's mind boggling! I mean a high schooler could write a clearer explanation.

Having read all the guidelines verbatim, I see no other way to interpret the rules other than to
a)- develop your ESP skills or
b)- have a written note from the referring doc, stating his/her intentions, **prior** to coding the visit. Technically, you have to have this request recorded in your chart in order to charge the consult. Also, you have to document that you sent your "expert opinion" back to the referring doctor. Otherwise, new patient visit.

Which is all such BS because NONE of the referring doctors are going to use the required verbage- "I'm sending this patient for your expert opinion" they say "I'm referring you a patient" so you still have no idea. My problem is if you are audited, you do NOT have a defensible position in most of these cases based on the wording the Audit Nazis are looking for. So I don't chance it.

So now I'm back to Gorback's original excellent advice, don't bill consults 99% of the time... which started a whole other great discussion that was probably much more important in the grand scheme of things! 😍

I like to pretend that the people who designed this consult coding were used to inpatient consults, where things are black and white- patient is on your service, or they are not, and then you are consulting.

But what I really think is they purposely made it difficult so we give up... just more cognitive dissonance by Big Brother. 🙁
 
But what I really think is they purposely made it difficult so we give up... just more cognitive dissonance by Big Brother.

Never attribute to malice that which can be explained by mere stupidity.

When it comes to billing, the best advice is to not be a standout. The tallest patches of grass usually get cut first.
 
gorback said:
But what I really think is they purposely made it difficult so we give up... just more cognitive dissonance by Big Brother.

Never attribute to malice that which can be explained by mere stupidity.

When it comes to billing, the best advice is to not be a standout. The tallest patches of grass usually get cut first.
Click to expand...
No need for ESP - David Vaughn, ESQ, CPC, in Baton Rouge devised a form you fax to your referring physician with the exact verbiage.

He/she checks off the appropriate response, puts a copy in his chart, and faxes his completed form back to you. Al done by your staff, no time or work for you, and completely complies with the current coding requirements.

Contact him for the details.
 
well... here is a way around this "sticky" situation

you provide the referring doctors with "referral" forms that are pre-scripted to say: reason for consultation - pharmacological consultation - back pain/spine consultation...

they then fax it over for their referrals and voila you have a form signed by them that clearly states it is a consultation

i keep a copy of the notes sent back to them with the consultation report

and therefore i bill 90-95% of my visits as consultations...
 
You can call your reports Valentine's Day cards, but if you initiate treatment it still isn't a consult.
 
gorback said:
You can call your reports Valentine's Day cards, but if you initiate treatment it still isn't a consult.
Click to expand...
Silly silly Gorback - it is whatever medicare says it is, and so long as you meet THEIR definition (as opposed to the logical, reasonable, or dictionary definitions
) it is acceptable to call it, and bill for, a consult.

Now personally, I am a big believer that you can either sleep well OR eat well, but not both. Personally, even though it meets the definition of a consult, I still bill it as a new patient visit. The $25 differential isn't worth my not sleeping well at night, but that decision is up to the individual practitioner and their personal comfort level.
 
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf

requirements
1) request from an appropriate source
2) consultation (ie: report)
3) written report back to initial source
4) diagnostic/treatments may be initiated at the time of consultation or during follow-up visits (i suspect this is what you were implying with the valentine's card)
5) return visits are not consultations - they are established patients

there is a relatively new requirement that the referring physician record in their medical record the request for consultation - this is done by my office with a "reverse" fax form (actually downloaded it from the texas medical association - works quite well).

trust me, i love sleeping at night - and i also like maximizing my reimbursements based on services I actually provide.... if you guys convince me that I am in the wrong, then I would gladly change my habit because i would hate to get in trouble.

I have had several Medicare Audits of my notes (progress notes and consultations) - and all of them have passed... i realize that in of itself it isn't confirmation of anything...
 
I hope you continue with your successes on this issue Tenesma. They are definitely profiling, and there is such a thing as being "dead right". The justice system is a wonderful thing but you don't want to get any of it on you. Being right can get very expensive.
 
gorback - i hear you... i'd hate to pay to be right... if it's going to cost me.

last year I hired a coding consultant to review my charts - she sampled 400 of them and told me I was under-coding and then showed me the bell-curves for multiple large single-specialty groups (cardiology, gastroenterology, endocrinology) and i was behind their curves as far as E/Ms go... so i now charge CPTs based on the work i actually do and I try to keep my bell-curve in mind...

here is the more interesting question - are we held to the same standards with work. comp. and private insurers when it comes to consultations?
 
So far I have not seen that, but they are definitely profiling. BCBSTX has a product called "Solutions" and only the "cost-efficient" docs are allowed to participate. They seem to make the determination every year or so.

I have been cycled on and off twice - on, then off, on again, then off again (as of 12/07 - just got the letter). The disruption of care this causes is very concerning. I lost some patients when I was "deselected". Some of them came back when I was "reselected", and then I was just deselected again so they have to leave again. This is disgusting.

Fortunately the "Solutions" product isn't all that popular and will impact few patients, but one of them is a pump patient and we all know how hard it can be for them to find another doctor. It is also usually a much closer relationship than one might typically have with other patients.

I am very displeased about this situation and I might file a complaint with the state. I really think they have gone too far. Can you imagine what this could do in a psychiatric practice? Some of those patients will kill themselves if the shrink just takes a vacation.
 
ampaphb said:
No need for ESP - David Vaughn, ESQ, CPC, in Baton Rouge devised a form you fax to your referring physician with the exact verbiage.

He/she checks off the appropriate response, puts a copy in his chart, and faxes his completed form back to you. Al done by your staff, no time or work for you, and completely complies with the current coding requirements.
Click to expand...

I have heard about this technique and it seems like a good one for most instances. My only concern would be if, subsequent to this fax, you received one of those nice letters from the referring doctor saying "I can't deal with this patient and the escalating oxycontin anymore, can s/he be your problem now, please and thank you."

Now the referring doctor has clearly indicated they want to transfer care and this is no longer billable as a consult. Auditors look for these kind of discrepancies in your chart. If you have what I lovingly call a "lick 'em and stick 'em" practice that ONLY does interventions and you NEVER follow the patents, but always send them back to the referring doctor for further management, then you are probably safe to bill lots of consults. However, if you take lots of chronic pain "dumps" that transfer care to you, watch your consult billing.
 
i don't think there is any reason that anybody should feel obliged to take dumps... and once you start taking them you will never be able to stop that flow...
 
Tenesma said:
i don't think there is any reason that anybody should feel obliged to take dumps... and once you start taking them you will never be able to stop that flow...
Click to expand...

So true, so true!

A dump, leading to a flow? Might need some Immodium! :laugh:
 
My wife is a doctor and she always has to refer her patients to another doctor because they suffer of prescription drug addiction and that's not her area of work.
 
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