Part B Insider (Multispecialty) Coding Alert

Published on Sun May 27, 2007 PDF

But don't cut the requesting doctor out of the loop

Good news: One carrier issued a new -frequently asked questions- (FAQ) item on the confusing issue of consults. A provider asked Palmetto GBA a straight question, and Palmetto managed to give a straight answer.

The question: Can a provider start additional testing or treatment at an initial consultation and still have the visit considered a consult?

Palmetto's answer: Yes. A physician or qualified non-physician practitioner can start diagnostic services and treatment at the initial consult or a subsequent visit. But you shouldn't bill for -ongoing management- after the first consult using consultation codes. Instead, you should bill for later visits using the subsequent visit codes.

Palmetto does include one cryptic sentence at the end: -Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.- And of course Palmetto doesn't define -transfer of care.-

But still, the Palmetto clarification is helpful, say experts. -Any time physicians initiate treatment, they are still in okay territory to bill a consult,- says Quinten Buechner with ProActive Consulting in Cumberland, WI.

-Patients are sent for evaluation, and part of that evaluation may be to order a test to confirm the evaluation and establish a diagnosis,- says Heather Stecker with Cardiology Consultants of Philadelphia. -Any future services made or follow-up appointments should be established visits,- she adds. -It is all about the intent of the visit.-

For example: Dr. X, a primary care physician, sends a patient to Dr. Y, a cardiologist to -evaluate the new onset of chest pain and shortness of breath to determine if there is a cardiac etiology.- This is a consult because Dr. X wants Dr. Y to evaluate the patient. Dr. Y can order an echo study and EKG.

For a consult to be valid, Dr. X must sign off on all medical care related to the reason for the consult, notes Jim Collins with the Cardiology Coalition in Saratoga Springs, NY. -To be safe, consulting physicians should echo the request for a consultation as their chief complaint in every visit note they will be billing as a consultation,- Collins adds. 

But if Dr. X sends the patient to Dr. Y to manage his chest pain and shortness of breath, then this means a transfer of care has happened, says Stecker. You should bill a new-patient visit (99201-99205).

The Medicare Claims Processing Manual (Chapter 30) says that a transfer of care is an agreement between two doctors for the specialist to take over the patient's care, notes Buechner.

After an initial consult, Dr. Y can give more treatment recommendations, and then Dr. X can decide whether to transfer the patient's care to Dr. Y, notes Rena Hall with Kansas City Neurosurgery.