Expel Consultation Code Worries

Substantiate incident to and transfer of care claims.

By G. John Verhovshek, MA, CPC

Readers wrote Coding Edge with questions concerning coding rules for consultation services 99241-99245, 99251-99255 (see “Consult or Not? Here’s How to Know for Sure,” May 2009 and “Coding Consultations When Components or Time is a Factor,” June 2009).

Can a Consult Be Incident To?

Kansas City Chapter member Patti Frank, CPC, asks, “I understand that a consultation cannot be a shared/split service. But can a consultation be billed incident to the collaborating physician, or must a consultation always be billed under the NPP’s own number? Please address both Medicare and commercial payers.”

For commercial payers, the honest response is, “We can’t tell you.”

Rules governing non-physician practitioner (NPP) billing services for commercial payers depend on the individual payer and its contract with the provider or facility. Because these arrangements frequently are proprietary, the only way to know the rules for sure is to check your contract or otherwise inquire with the payer.

For Medicare, NPPs acting within scope-of-practice may bill consultation services under their own provider numbers—provided all service requirements have been met and documented. NPPs should not report consultation services under a physician’s provider number or incident to physician services.

This answer is not as simple as it seems.

According to the Medicare Benefit Policy Manual, chapter 15, section 60.2, an NPP “may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service.”

In other words, Medicare will allow an NPP, acting within scope-of-practice in her state, to report consultation services under her own provider number in either the inpatient or outpatient setting. For this to happen, however, a number of conditions must be met:

-The NPP must be able to provide the full range of service expected by the requesting source.

“The entire justification for a consult is that the consulting provider’s knowledge goes beyond that of the requesting provider,” notes Jill Young, CPC, CEDC, CIMC, president of Young Medical Consulting, LLC, and vice chair of the AAPC Chapter Association. “Ideally, the medical record will substantiate that the NPP has relevant expertise to provide the consult. For instance, an NPP providing a cardiology consult might note that she is certified in the area, or has 20 years experience working in that field.”

-The service must be requested of the billing NPP specifically. That is, if the consultation is requested of a physician, an NPP cannot “take the place of” the requested physician in providing the service.

-In the inpatient setting, the NPP must have consulting privileges with the hospital or facility.

“Hospitals offer different kinds of privileges—admission privileges, procedure privileges, and so on,” Young stresses. “An NPP cannot report an inpatient consultation if she doesn’t have consulting privileges with the individual facility.”

-The same medical necessity and documentation requirements for evaluation and management (E/M) services apply to NPPs as to physicians.

Remember, consultation services cannot be shared. If an NPP confers with a physician at all, the service is deemed shared or split and may not be billed as a consultation.

For Medicare, payment for NPP services is 85 percent of the allowable fee schedule amount. In contrast, reporting services incident to a physician’s services allows the NPP to bill under a supervising physician’s provider number, which provides 100 percent reimbursement of the fee schedule amount.

Incident to guidelines do not apply in the hospital setting. The Medicare Claims Processing Manual, chapter 12, section 30.6.13.E, states flatly, “‘Incident to’ E/M visits, provided in a facility setting, are not payable under the Physician Fee Schedule for Medicare Part B.”

In an office setting, incident to payment for Part B services applies when the incident to criteria, as described by the Medicare Benefit Policy Manual, chapter 15, sections 60.1-60.3, have been met. Among other requirements, these guidelines specify, “a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment” (60.1.B).

Section 60.2 of the same document further explains:

“A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. As explained in §60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.”

The requirement that a physician provide an initial service means that an NPP could not report an incident to consultation. If the physician has met with the patient and initiated a course of treatment, there is no medical necessity for a subsequent NPP consultation.

“The NPP may provide services subsequent to the physician’s initial meeting with the patient, and these services may be incident to, but an NPP would not provide the initial consultation or other initial service incident to,” Young confirms.

Not Every Referral Means a Consult

Another reader wanted to confirm the importance of the requesting physician’s intent in determining if a consultation services may be reported. She expressed frustration that her physician treats as a consult every patient referred to him by another physician.

The first question to consider when deciding if a medically-necessary service may be classified as a consultation is, “Was the referring physician asking for an opinion or advice so he could continue to treat the patient?” If not, the service can’t be a consult, regardless of whatever documentation requirements the service might meet.

The Medicare Claims Processing Manual, chapter 12, section 30.6.10.B (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) states, “A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ 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.”

When a transfer of care occurs, 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, rather than a consultation.

For example, an emergency room (ER) physician treats a patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. In this case, the orthopedist would not report a consultation service because advice or opinion is not required by the ER physician.

If there’s any doubt as to the referring/requesting physician’s intent for sending the patient, seek clarification. The consulting physician should be careful to document the service precisely. For instance, the procedure note might begin, “I am seeing [patient] today at the request of [referring physician] who has asked I evaluate the patient in consultation for [condition and/or signs and symptoms] and recommend treatment so that [referring physician] may continue to care for [patient]. Based on findings: [list findings]; I recommend: [list treatment options, etc.].” Such a statement substantiates the consultation request, reason, and report, and readily identifies the service’s true intent.

As always, the standard components of an E/M service (history, exam, medical decision-making, time, etc.) must be performed and documented appropriately for the level of service reported.

G. John Verhovshek, MA, CPC, is AAPC’s 
director of clinical coding communications.


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