Determine Service Level for Cardiology Consultations

In a new educational article, Palmetto GBA reminds cardiologists and staff  to accurately select the service level when submitting consultation claims for services rendered before Jan. 1, 2010. According to the jurisdiction 1 Part B Medicare administrative contractor (MAC), a review of documentation by the Comprehensive Error Rate Testing (CERT) contractor indicates ongoing problems with the medical record not supporting the submitted code for consultations by these specialty physicians.

Requirements for Consultations

Consultations are distinguished from transfers of care by the three Rs:

  • Request for opinion or advice from the referring physician
  • Render an opinion or advice (consulting physician)
  • Written report by the consulting physician to the referring physician or health care practitioner

For each consultation CPT® code, documentation must support each of the three key components of the service at the required level:

  • The three key components of evaluation and management (E/M) services are: history, exam, and medical decision making.
  • You may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services in selecting the correct CPT® code, but not both.
  • Cardiology consultations submitted to Medicare must meet the minimum requirements for the CPT® code selected. If any one of the three key components is not documented at the required level, select a lower service level.
  • The medical decision making component is not the sole deciding factor in selecting the correct CPT® code.

You may use time as the key or controlling factor in selecting a code only if the consultation consists predominantly of counseling or coordination of care. In other words, at least 50 percent of the time spent with the patient must be spent counseling or coordinating care to use time alone in selecting the CPT® code.

Refer to the article on the Palmetto GBA website for tables that show the requirements for each service level for consultations.

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