HCFAs New Guidelines Tactics to Improve Payment for Consultations
Published on Mon Nov 01, 1999
In August 1999, HCFA added a definition of consultations (99241-99275) to the Medicare Carriers Manual (MCM), a clarification that will prove useful to oncology coding professionals in determining when an oncologist has assumed responsibility for care of a cancer patient versus when they are actually performing a consultation. Financially this is very important, because the consult codes reimburse at a higher rate than the in-office or inpatient exam codes.
There are three key elements in a consultation:
1. a request for opinion or advice about a patient from one physician (or other appropriate source) to another;
2. performance and documentation of that service by the consultant; and
3. communication of the opinion or advice back to the requesting physician.
The previous, somewhat ambiguous, MCM explanation of consultations has been expanded from a few paragraphs to nearly three pages and includes helpful examples:
A. When a Consult Changes to Assumption of Care.
Consultation changes to assumption of care in one of two ways:
1.) When the physician (or other appropriate source) requesting a consultation transfers responsibility for complete care at the time of the request or
2.) visits subsequent to the initial consultation where the consulting physician is now managing a portion or all of the patients treatment.
The consulting oncologist may begin diagnostic or therapeutic services during the initial encounter with the patient even though that evaluation is billed as a consultation (99241-99275). After that point, the consultant has assumed care. Therefore, if the oncologist sees the patient again, that next visit will be billed as an established patient visit (99211-99215, outpatient; 99231-99233, inpatient).
For example, a surgeon sends a 60-year-old male patient with Stage III colon cancer to see a medical oncologist concerning possible chemotherapy following surgery. The oncologist orders a chest x-ray to rule out lung metastases. The initial visit is correctly billed as a consultation. The next visit, however, is billed as an established patient visit (MCM 15506, August 1999).
In the case of a patient with invasive ductal breast cancer, the surgeon who performed the biopsy and mastectomy probably would seek a consultation from both a medical oncologist and a radiation oncologist concerning the need for further treatment. Each oncologist would see the patient, most likely in the office, do an evaluation, and each would render an opinion concerning treatment. Each would respond to the surgeon, in writing, with the opinion. That would complete the consultation, which would be billed as an outpatient consultation (99241-99245).
B. Inpatient vs. Outpatient Consults.
The major difference between in- and outpatient consultations is the number of consults allowed.
1. Inpatient: According to CPT rules, the consulting physician is limited to [...]
