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Reimbursement Advisor

A consult calls for more expertise, not less

May 2005 · Vol. 17, No. 5
This week's quiz:
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<huc>Q</huc> A patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

<huc>A</huc> No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

OBG Management ©2005 Dowden Health Media
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