Medicare Compliance & Reimbursement

You don't have to verify documentation, but it should be there.

You've been tearing out your hair over the confusing consult documentation rules--and they just got even more complicated.

The Centers for Medicare & Medicaid Services tried to let providers off the hook for the consult catch-22, but CMS's latest clarification just raises more questions, say providers.

New rule: A statement by the Physician Regulatory Issues Team at CMS says that the consulting physician doesn't have to verify that the requesting physician documented the request for a consult. In other words, when Doctor A requests a consult from Doctor B, it's not up to Doctor B to make sure Doctor A's files include that request in writing.

But CMS officials say that Doctor A still has to document the request for a consult, as CMS stated in last December's Transmittal 788. The only change is that Doctor B doesn't have to verify that Doctor A has done so.

It's not clear what will happen if the carrier audits Doctor B and doesn't find any request documented in Doctor A's files. Will Doctor B still get paid for consults without that documentation?

"It is a real paper chase for the consultant to have to look at the referring physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, CA. CMS should delete the requirement for Doctor A to document the request for a consult altogether, she adds.

Chances for clarification: But CMS officials say they're not planning on clarifying the consult issue any further--unless providers or carriers indicate that that they're still having problems with the issue. CMS doesn't even plan to put out a transmittal or manual update spelling out this latest clarification partly letting consulting physicians off the hook.