Otolaryngology Coding Alert

Don't let narrow interpretations stop you from using 99241-99245 for tube candidates

You can confidently code consultations for probable surgical patients -- but only if you can interpret what Medicare means by the simple phrase -complete care for the condition.-

Otolaryngologists are reeling from phrases that Medicare added to its consultation wording. The transfer-of- care rule, for example, is -a change to which we are continuing to object,- says Stephen R. Levinson, MD, managing member of ASA, LLC, author of Practical E/M: Documentation & Coding Solutions for Quality Patient Care; and a Fellow of the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS).

Rather than be subjected to the various interpretations milling about consultation coding, get the facts yourself.

Understand the Fury-Causing Words

The new guideline that scares physicians says, -Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.- In language introduced to the Medicare Claims Processing Manual section 30.6.10 -- Consultation Services on Jan. 1, 2006, in Transmittal #788, CMS then describes:

-A transfer of care occurs when a physician - requests that another physician - 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.

-When this transfer is arranged, the requesting physician - is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition- [emphasis added].

Fall out: The reference to -complete care for the condition- has led to numerous interpretations of consultation codes- applicability. -It is unclear whether [the phrase] means that physicians performing consultations are precluded from billing for an initial consultation if any transfer of care is involved,- says an Oct. 26, 2006, AMA letter to CMS Acting Administrator Leslie Norwalk, Esq, CMS, in which numerous associations and societies including the AAO-HNS request assistance in revising the Medicare consultation policy.

See It From CMS, AMA Perspectives

Argument 1: Interpreting the phrase narrowly -- to mean no consult when any transfer of care occurs -- would make a consultation a rare occurrence. If the transfer-of-care verbiage -were the only text in the transmittal, it would be reasonable to conclude that many visits that have been considered consultations would not qualify because the requesting physician anticipates that the consultant will be primarily responsible for handling treatment of the problem,- writes David Glaser, an attorney with Fredrikson & Byron in the article -New Guidance Related to the Consultations Codes- published in Fredrikson & Byron's Health Law Flash Focus, January 2006.

Argument 2: The AMA letter furthers the idea that a tight interpretation of transfer of care is inappropriate. -We understand that the CPT Editorial Panel is reviewing coding clarifications regarding the use of consult codes within the context of a transfer of care which would specify that a transfer of care does not preclude use of a consultation code.-

Nail Down Intent to Protect 99241-99245 Pay

The problematic nature of this jargon becomes apparent when you try to determine whether the following ENT example qualifies as a consultation. The scenario: An otolaryngologist sees a patient for possible tubes due to chronic OM at the request of a pediatrician. Based on history and examination, the ENT recommends that the child have tympanostomy (69433, Tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia) and discusses the surgery with the parent. He then sends the requesting physician a report of his recommendations.

Note: Although the above is a typical pediatric ENT scenario and CMS rules do not directly apply to pediatric patients, many third-party payers will follow Medicare guidelines. In fact, Medicare consultation guidelines applicability was requested on the given scenario that was submitted by an attendee of the 2006 AAO-HNSF Annual Meeting & OTO EXPO in Toronto.

The debate: Some experts argue that because the surgeon assumes treatment and care of the problem that a transfer of care has occurred and thus a consultation code is inappropriate. -The key is the requesting physician's intent,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. She suggests using a new patient letter that firms up the requesting physician's intent.

Tip: You can also use language in the consultation report that indicates the requesting physician is still in the loop. Cobuzzi and Glaser suggest concluding the report with a phrase such as -Unless I hear otherwise, I will continue with the plan of care as discussed above.- -This gives the requesting physician an opportunity to disagree with the plan of care and indicates that he or she is continuing to control the patient's care,- Cobuzzi says.

Check Out 2 Consult Examples

CMS doesn't seem to consider that the above precludes a consultation. -- a review of the examples CMS includes in the transmittal suggests that if the requesting physician will be monitoring the patient for reoccurrence or to facilitate or evaluate the treatment in any way, then the visit still qualifies as a consultation,- Glaser says. -The transmittal includes several examples of visits that should be considered consultations.- 

In Transmittal #788 an example that qualifies as a consultation describes a family practice physician who diagnoses a patient with a breast mass and sends the patient to a general surgeon -for advice and management of the mass and related patient care. The general surgeon examines the patient and recommends a breast biopsy, which he schedules, and then sends a written report to the requesting physician. The general surgeon subsequently performs a biopsy and then periodically sees the patient once a year as follow-up. Subsequent visits provided by the surgeon should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Following the advice and intervention by the surgeon, the family practice physician resumes the general medical care of the patient.-

Although the general surgeon assumes care of the problem, an initial consult prior to transfer of care of that problem is allowed. The key, Glaser says, is that the -requesting physician is still monitoring the patient for problems that develop, recurrence or complications.-

 The AMA letter to CMS requests clarification of this interpretation. -While the complete care of a patient may be transferred from one physician - to another physician -, the more common scenario is a complete transfer of care for the particular condition which necessitated the consultation. For example, a primary-care physician may refer a patient with a skin condition to a dermatologist for a consultation regarding that condition. The dermatologist may determine, after examining the patient, s/he needs to continue to receive dermatological care. However, the patient's primary care continues to be handled by the referring physician. Given this common scenario, we request CMS specify in Medicare Transmittal #788 that a consultant can bill for an initial consultation prior to the transfer of care for the condition that necessitated the consultation.-

A parallel can be seen in the case of the possible tubes patient. Based on examination, the ENT may decide the patient needs to undergo tympanostomy. The pediatrician continues to handle the patient's primary care. After surgery, -the PCP is going to be looking in the patient's ears, watching the patient for problems that develop, such as possible infection or another otitis media,- Glaser says. This return to the PCP completes the circle of care indicative of a consultation. The encounter qualifies as a consult if documentation supports the request and report requirements.

The revised portions of the Medicare Claims Processing Manual are attached to CR4215. These revisions include examples that meet the consultation services criteria and some examples that do not. CR4215 may be viewed at www.cms.hhs.gov/transmittals/downloads/R788CP.pdf on the CMS Web site. For the letter requesting changes to this transmittal, go to www.idsociety.org/Content/ContentGroups/Public_Statements_and_Policies1/Comments/Consult_Sign-on_letter-FINAL_102306.pdf.