Medicare Compliance & Reimbursement

Safety first: Get some kind of documentation on consult request for patient record.

Last September's transmittal on incident-to billing wasn't the only thing that the Centers for Medicare and Medicaid Services withdrew without any explanation.

CMS had issued a new Medlearn Matters article about consults in which the agency said definitively that a doctor doesn't need a letter from the requesting physician to prove a visit was a consult. Instead, CMS said, the doctor just needed a note in the patient's medical record.

But now CMS has removed Medlearn Matters article SE-0515 from its Web site and told the carriers to take it back. After CMS' transmittal about "Medically Unbelievable Edits," which also disappeared, some are seeing a pattern of flip-flops from the Medicare agency.

The problem with issuing policies and then withdrawing them is that providers hear about the new policy but then don't hear it's been withdrawn, complains Eric Sandhusen, director of compliance with Columbia University Department of Surgery.

Luckily, in the case of consults, CMS' new advice wasn't too different from what consultants have been telling clients for years, according to Sandhusen. A letter from the referring physician isn't necessary, but a provider does need documentation in at least the consulting physician's files and ideally in both doctors' records.

Sometimes providers believe that patients need to show up for a consult with a note or prescription from the referring doctor requesting the consult, notes Mary Falbo, president of Millennium Healthcare Consulting in Lansdale, PA. The Medicare Carriers Manual says the record must have a written "notation" of the request for consult, but not that it has to be a request in writing. Smart Move: Note Verbal Consults In Record Often, one doctor will call up another, or meet him in the hall, and request a consult verbally, notes Sandhusen.

In that case, the consulting doctor should simply write in the patient's progress notes that she's evaluating the patient at the request of Doctor X, says Falbo.

The withdrawn article also clarified that if a physician provides a pre-operative consult and then takes over the management of the patient's postoperative care, the physician shouldn't bill a consult code. In addition, if the surgeon asks another doctor's help managing an aspect of the patient's postoperative care and that doctor doesn't provide a consultation, bill for the post-op care as "concurrent care," CMS explains.

Why so many flip-flops? CMS has been making documentation calls that are properly the purview of the American Medical Association and has had to eat its words in an ongoing turf war, says Falbo.

CMS is supposed to consult the AMA before making changes to documentation guidelines through transmittals and other means, Falbo explains.