Documentation is Crucial with Medicare Revision when Coding for Consultations
Published on Fri Oct 01, 1999
Documentation is still the key to getting paid for consultations, because while a recent Medicare clarification says consult physicians can initiate treatment there is still a question about complete care.
A previous series of clarifications by Medicare regarding what is and is not a consultation has done anything but clarify the issue for many otolaryngologists. This new Medicare revision, however, may be a step in the right direction. According to Transmittal No. 1644 (Medicare Carriers Manual), which recently went into effect, a consult may be billed regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.
Therapeutic/Diagnosis Treatment
According to some coding experts, the new revision means the physician performing the consultation now can initiate therapeutic as well as diagnostic treatment on the same day, as long as complete care of the patient has not been transferred, and the otolaryngologist is not simply following the instructions of the requesting physician.
Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Phoenix, AZ, believes the new revision will make it much easier to bill for consults. Before, our understanding of the consult was that if the doctor treated the patient it wasnt considered a consult, it was an office visit. All the otolaryngologist and other specialists could do was offer advice and their opinion to the requesting physician. To initiate treatment, he would have to stop and call the attending physician.
Zmuda adds that when a patient comes in to see the otolaryngologist and needs help, the last thing the physician wants to say is, Look, I know whats wrong and how to treat you, but I need to talk it over with your PCP first. So they would treat the patient before talking with the PCP, and consequently, couldnt bill for a consult. Now, she says, they can initiate treatment.
Under the new guidelines, if the pediatrician, as the attending primary-care physician, sends a 10-year-old boy with a chronic ear infection to the otolaryngologist after treating him repeatedly with antibiotics, and the ENT evaluates the child by doing a culture of the ear to determine what kind of bacteria is causing the infection and gives the child IV antibiotic therapy, the otolaryngologist may still claim for a consult.
The new guidelines are telling us that if a doctor sends the patient to a specialist and asks for opinion and his advice, and the documentation states that, he can go ahead and initiate treatment of the patient, Zmuda says.
Confusion Over Complete Care
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