Part B Insider (Multispecialty) Coding Alert

Published on Tue Mar 28, 2006 PDF

Doctors can request consults from others in the same group

You may have spotless documentation for the consultations your physician performs, but you could still lose your consult reimbursement in an audit, thanks to some new rules.

In Transmittal 788, dated Dec. 20, the Centers for Medicare & Medicaid Services says:

• You have to have documentation of the consult request in both the consultant's records and the requesting physician's records. The request must be part of the requesting physician's plan of care for the patient, CMS says.

• Non-physician practitioners can perform consults, but you can't bill for the consult as a split/shared visit.

• A consult shouldn't be the same as a transfer of care, and the consultant shouldn't take over the management of "patient's complete care for the condition." For a transfer of care, bill the appropriate new or established patient evaluation and management code.

• A physician or NPP can request a consult from another physician or NPP in the same group, as long as the consultant has "expertise in a specific medical area beyond the requesting professional's knowledge."

The new requirement for the requesting physician to document the request for a consult is "a Catch 22," says Steven Levinson, an otolaryngologist in Fairfield, CT and author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care. "If I call the doctor who's referring me patients every six days, and say please send me a photocopy of your chart that shows you documented the consult, I soon will not have any consults."

Wise idea: "The medical record should indicate" if the physician requests a consult, CMS official Kit Scally insisted on the Jan. 20 physician Open Door Forum. If one physician meets another in the hallway and verbally requests a consult, they should both document that fact. But if the physician phones in the consult request to the other doctor's staff, you should document that circumstance too, she said.

Note: For guidance on complying with the four R's of new consult coding, refer to an article later in this issue.