Medicare Compliance & Reimbursement

Providers need to make sure they have the written request in their files.

Most consults are medically necessary--they just have documentation problems, says one top CMS official.

But providers won't get into trouble if they bill a consult and it turns out that the physician who requested the consult didn't have the request documented in his or her files, confirms William Rogers, director of the Physician Regulatory Issues Team at the Centers for Medicare & Medicaid Services.

The requesting physician is still required to document that request, but it's not the consultant's responsibility to verify that documentation in the requester's files, says Rogers. If the requesting physician fails to document the request for a consult, he or she may not have any reimbursement at stake--but CMS will still hold him or her accountable for bad documentation, says Rogers.

"We're saying to the consultant, 'Do the consultation, that's the most important thing,'" says Rogers. "To delay a consult 24 hours on an ICU patient because you can't find the written request is difficult to support," he adds.

That still doesn't let consultants off the hook, however. A couple of problems remain.

Problem #1: CMS also wants the consulting physician to have a written document from the physician requesting the consult. But this could prove tricky, says Amanda Kunze, a coder with Wenatchee Eye & Ear Clinic in Wenatchee, WA.

Providers should either make sure there's a written referral or have a consult request form that they can fax to the requesting physician, advises Quinten Buechner, consultant with ProActive Consulting in Cumberland, WI. You can call the other office and let them know the fax is coming, so they'll be ready to fill it out and fax it back.

Buechner has a check-box form that allows the requesting physician to specify what he or she is asking for. Options include: advice and treatment, advice and management suggestions, second opinion, evaluation and treatment, opinion and recommendation of care, and recommendation for further care after evaluating the problem. There's also a space to write down the problem.

Problem #2: CMS' new consult guidelines also hint that if the consulting physician goes ahead and treats the problem which led to the consult, that's no longer considered a consult. Instead, it's a transfer of care. The medical director of Part B carrier Noridian came to Wenatchee and told Kunze and other providers that they can't bill a consult if they're also initiating treatment. A consult is only for providing an opinion back to the requesting physician.

"It's going to be really hard to determine what a consult is and what it isn't," says Kunze.

For example, CMS' new manual update on consults includes examples of correct consult billing. One of these involves an internist who sends [...]