Cardiology Coding Alert

Latest Medicare Clarification on Consultations Gets Mixed Reviews

Cardiologists, like all medical specialists, often are called on to share their expertise with an attending physician. However, a series of previous clarifications by Medicare regarding what constituted a consultation (99241-99275), as opposed to a transfer of care, did anything but clarify the issue for many cardiologists.

A new Medicare revision, however, may be a step in the right direction. According to Transmittal No. 1644, which was issued on August 2 and went into effect August 26, a consult may be billed regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.

According to some coding experts, the newest revision means the physician performing the consultation now can initiate therapeutic as well as diagnostic treatment on the same day, as long as complete care of the patient has not been transferred, and the cardiologist is not simply following the instructions of the requesting physician.

Note: If, for example, a family practitioner (FP) sends a patient to a cardiologist and specifically requests a stress test, that would not be considered a consult, because the cardiologist is following the FPs instructions.

Cynthia Swanson, RN, CPC, a management consultant with Seim, Johnson, Sestak, Quist, LLP, an accounting and healthcare consulting firm in Omaha, NE, describes the revision as a big step in the right direction.

The revision helps makes it much clearer to Medicare carriers that even though the cardiologist is initiating diagnostic services, he or she is still performing a consultation, Swanson says, adding that the revision brings Medicare closer to the definition of a consultation in CPT 1999, which clearly states that a physician consultant may initiate diagnostic and/or therapeutic services.

What Medicare had interpretedand it was reflected in their carriers reimbursementwas that if the cardiologist took over any aspect of managing the care of the patient, it wasnt a consult, it was a referral, she explains. With the revision, Medicare carriers have a clearer idea of what Medicare meant by transfer of care.

To illustrate the effect of the revision, Swanson cites the example of a family practitioner who sees a male patient complaining of chest pains and difficulty breathing when he exercises. Suspecting cardiac problems, the family practitioner sends the patient to a cardiologist, who then takes the patients history and gives him a physical. The cardiologist then contacts the FP to say that the patient needs a thalium stress test. The results of that test, explains the cardiologist, will determine the patients course of treatment and, therefore, whether a transfer of care will occur.

In other words, the decision to run the stress test occurs during the consultation. In effect, the cardiologist informs the FP that treatment of the patient will depend on the outcome of the test. If the test indicates problems beyond his or her level of expertise, the FP might then transfer care of the patient to the cardiologist.

Meeting the Basic Requirements

The entire scenario outlined above would constitute a consultation under HCFAs revised guidelines, as long as the basic requirements of a consult were met. These are:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the requesting physician.

The request for a consultation should be retained in the patients files in case Medicare asks to see it subsequently.

Kathleen Mueller, RN, CPC, CCS-P, who works as a nurse and practice coder in the office of Allan Liefer, MD, in Chester, IL, agrees that the HCFA clarification makes it easier for specialists to bill for consults, particularly in the hospital setting.

Before, you couldnt bill a consult when you took over any aspect of the patients care in the hospital. Instead, you had to bill a subsequent hospital visit, because Medicare carriersthrough their interpretation of section 15506 of the Medicare Carriers Manualdecided that if the physician had assumed partial care of the patient, they no longer could claim a consult, Mueller says. With the August revision, she says, partial care still is considered
a consult.

However, Mueller notes that if the requesting physician (typically, a general or family practitioner) transfers complete care of the patient to the specialist, consults cannot be billed.

Complete Care is Still Unclear

Other reimbursement specialists are not so sanguine about the effect of Medicares latest change. Everybody is excited about the revision, but the question of what constitutes complete care of the patient is still unanswered, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in N. Augusta, SC, who was recently named Coder of the Year by the American Academy of Professional Coders.

She warns physicians not to get too relaxed about billing consults under the new guidelines, noting that the revised descriptions in Sections A and B of 15506 contradict the unrevised wordage elsewhere. Stradley cites the guidelines for consults during postoperative care provided in Section G, and says the definition of transfer of care provided there differs from that in Sections A or B. According to Section G:

If the surgeon asks a physician who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patients condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physicians opinion or advice for the surgeons use in treating the patient. The physicians services would constitute concurrent care and should be billed using the appropriate level visit codes.

In other words, Callaway-Stradley says, the persistent problem of reconciling one longstanding definition of a consultas an opinion or advice onlywith treating the patient has not been satisfactorily resolved and will likely be interpreted differently by various Medicare carriers.

Callaway-Stradley points to Medicares prior revision of 15506 on June 26, 1998, which indicated that a consultant may initiate diagnostic and/or therapeutic services, left the question of transfer of care unanswered. This latest revision, she says, tried to resolve that issue, but failed to define complete care. Until that is resolved, she says, cardiologists (and other specialists) can expect more confusion over whether to bill for consults.

The confusion has already spurred reports of carriers denying consults since Transmittal No. 1644 was issued. These carriers maintain that if the specialist treated the patient during his or her first visit, that constitutes a complete transfer of care, and thus they will deny the consultation.

Meanwhile, coding experts on both sides of the issue expect that continuing pressure from specialty medical associations could prompt yet another revision of this thorny issue in the Medicare Carriers Manual.