Part B Insider (Multispecialty) Coding Alert

Published on Thu Mar 10, 2005 PDF

But CMS withdraws its article on the subject, to providers' confusion

Last September's transmittal on incident-to billing wasn't the only thing that the Centers for Medicare and Medicaid Services withdrew without any explanation.

CMS issued a new Medlearn Matters article about consults in which the agency said definitively that you don't need a letter from the requesting physician to prove a visit was a consult. Instead, CMS said, you just needed a note in the patient's medical record.

But now CMS has removed Medlearn Matters article SE-0515 from its Web site and told the carriers to take it back. On the heels of CMS' transmittal about "Medically Unbelievable Edits," which also disappeared, observers are starting to see a pattern of flip-flops from the Medicare agency.

The problem with issuing policies and then withdrawing them is that providers hear about the new policy but then don't hear it's been withdrawn, complains Eric Sandhusen, director of compliance with Columbia University Department of Surgery.

Luckily, in the case of consults, CMS' new advice wasn't too different from what consultants have been telling clients for years, according to Sandhusen. You don't need a letter from the referring physician, but you do need documentation in at least the consulting physician's files and ideally in both doctors' records.

Sometimes providers believe that patients need to show up for a consult with a note or prescription from the referring doctor requesting the consult, notes Mary Falbo, president of Millennium Healthcare Consulting in Lansdale, PA. The Medicare Carriers Manual says the record must have a written "notation" of the request for consult, but not that it has to be a request in writing.

Often, one doctor will call up another, or meet him in the hallway, and request a consultation verbally, notes Sandhusen.

In that case, the consulting doctor should simply write in the patient's progress notes that she's evaluating the patient at the request of Doctor X, says Falbo.

Make Your Own Form

Some consultants do recommend making your own form for consults, notes Laureen Jandroep, director and senior instructor with the CRN Institute. That way, when you receive the phone call from Dr. X's office, you can fax back a form for Dr. X to sign requesting the consult. This isn't required, but does give you extra protection.

Some specialists believe that every referral from a primary care physician is a consult, but it varies by specialty, says Jandroep. A neurologist likely will receive more consult requests than an orthopedic physician. Usually, a referring physician will already know a patient has a broken arm, so the referral source most likely will want help treating the patient rather than confirming a diagnosis.

The withdrawn article also clarified that if a physician provides a pre-operative consult and then takes over the management of the patient's postoperative care, you shouldn't bill a consult code. In addition, if the surgeon asks another doctor's help managing an aspect of the patient's postoperative care and that doctor didn't provide a consult, you should bill for the post-op care as "concurrent care," CMS explains.

Why so many flip-flops: CMS has been making documentation calls that are properly the purview of the American Medical Association and has had to eat its words in an ongoing turf war, says Falbo. CMS is supposed to consult the AMA before making changes to documentation guidelines through transmittals and other means, she explains