Medicare Compliance & Reimbursement

Treatment, tests don't mean the visit's not a consult.

Good news: One carrier issued a new "frequently asked questions" (FAQ) item on the confusing issue of consults. A provider asked Palmetto GBA a straight question, and Palmetto managed to give a straight answer.

The question: Can a provider start additional testing or treatment at an initial consultation and still have the visit considered a consult?

Palmetto's answer: Yes. A physician or qualified non-physician practitioner can start diagnostic services and treatment at the initial consult or a subsequent visit. But you shouldn't bill for "ongoing management" after the first consult using consultation codes. Instead, you should bill for later visits using the subsequent visit codes.

Palmetto does include one cryptic sentence at the end: "Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs." And of course Palmetto doesn't define "transfer of care."

Still, the Palmetto clarification is helpful, say experts. "Any time physicians initiate treatment, they are still in okay territory to bill a consult," says Quinten Buechner with ProActive Consulting in Cumberland, WI.

"Patients are sent for evaluation, and part of that evaluation may be to order a test to confirm the evaluation and establish a diagnosis," says Heather Stecker with Cardiology Consultants of Philadelphia. "Any future services made or follow up appointments should be established visits," she adds. "It is all about the intent of the visit."

For example: Dr. X, a primary care physician, sends a patient to Dr. Y, a cardiologist, to "evaluate the new onset of chest pain and shortness of breath to determine if there is a cardiac etiology." This is a consult because Dr. X wants Dr. Y to evaluate the patient. Dr. Y can order an echo study and EKG.

For a consult to be valid, Dr. X must sign off on all medical care related to the reason for the consult, notes Jim Collins with the Cardiology Coalition in Saratoga Springs, NY. "To be safe, consulting physicians should echo the request for a consultation as their chief complaint in every visit note they will be billing as a consultation," Collins adds. Consultants should also send a report to the requesting physician. 

But if Dr. X sends the patient to Dr. Y to manage his chest pain and shortness of breath, then this means a transfer of care has happened, says Stecker. You should bill a new-patient visit (99201-99205).

The Medicare Claims Processing Manual (Chapter 30) says that a transfer of care is an agreement between two doctors for the specialist to take over the patient's care, notes Buechner.

After an initial consult, Dr. Y can give more treatment recommendations, and then Dr. X can decide whether to transfer the [...]