Medicare Compliance & Reimbursement

It's not a consult if the requesting physician 'doesn't give a rip.'

Your cries for clarification of what constitutes a consult may have been answered.

Some physicians have worried that nothing would count as a consult any longer, ever since the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 788 last December. The transmittal clarified various consult questions, but also included a new definition of "transfer of care" that would make it much harder to bill for a consult.

The new definition reads: "A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition."

For example: Doctor A sends a patient to Doctor B for a consult on the patient's heart condition. Doctor B reports back to Doctor A, but also takes over treatment of the patient's heart problems. According to the new definition, this might be a lower-paying transfer of care, not a consult.

"We're aware of the problems that some are having with the transmittal," says William Rogers, head of the Physician Regulatory Issues Team (PRIT) within CMS. The PRIT, along with the Infectious Disease Society of America, the American College of Physicians, the American Medical Association and several specialty societies, has been working to hone the transfer definition language.

The examples of consults in the transmittals "all very much reflect what all of us have conceptualized as being a consult," Rogers notes.

At first glance, Transmittal 788 did appear to be "getting rid of consults," says attorney David Glaser with Fredrickson & Byron in Minneapolis, MN. "But based on the examples, nothing had changed."

Glaser hopes CMS goes back to the old definition of transfer of care: It's a transfer if the referring physician isn't going to be involved in any way with the patient's treatment afterward. "If the person who's requesting the opinion doesn't give a rip" about the patient's ongoing care, then it's a transfer of care, clarifies Glaser. In that situation, the requesting physician is "washing his hands" of the patient.

But Transmittal 788 did clarify one tricky issue, according to Glaser.

Suppose a patient goes to an emergency department physician for ankle strain and is told to visit an orthopod later in the week. Is the patient's visit to the orthopod a consult? CMS says no because the ED physician doesn't care what the orthopod says about the patient's problem.