Medicare Clarification on Consultations Gets Mixed Reviews
Published on Fri Oct 01, 1999
General surgeons are often asked to share their expertise with an attending physician. However, a previous series of clarifications by Medicare regarding what is and is not a consultation has done anything but clarify the issue for many surgeons.
Now a new Medicare revision (8199) may be a step in the right direction. According to Transmittal No. 1644, which recently when into effect, 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 new revision means that the physician performing the consultation can now 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 general surgeon is not simply following the instructions of the requesting physician.
Others say that until the definition of complete care is resolved, the issue will continue to fester.
A previous revision issued in June 1998 also stated that a consultant could initiate diagnostic or therapeutic services, but muddied the waters by stating that the visit could not be billed as a consult if partial or total care of the patient had been transferred. That meant that some carriersMedicare and commercialwould not pay for a consult if any aspect of the patients care was being managed by the specialist.
By clarifying when a transfer of care occurs, the new revision also 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.
Some coding experts maintain that the distinction between partial and total, or complete, is significant and makes it easier to defend the use of the consult, because they define total care as taking over all aspects of a patients treatment, including exams and services unrelated to the diagnosis that spurred the request for a consult. But others maintain that total care applies only to the condition the requesting physician sought advice for, and therefore, if the specialist initiates treatment for that condition, some carriers could interpret that as complete care.
Under HCFAs revised guidelines, the basic requirements of a consult 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 [...]
