Pulmonology Coding Alert

You aren't responsible for the requesting physician's files, CMS says CMS lets pulmonologists off the verification paper-trail hook, drops one critical care bundle and creates numerous moderate sedation bundles. Here's what you need to know to seamlessly implement these changes. Change 1: No Need to Confirm 1 Consultation 'R' Recent Medicare rules have had pulmonologists worried that they'd be responsible for other physicians' consult request documentation. CMS now says that this isn't the case, but it hasn't offered new guidance on how it will handle "incomplete" consult requests.

New rule: "On April 18, 2006, the PRIT (Physician Regulatory Issues Team) released a statement stating that they do not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient's chart," writes Diane Daigle, president of Maine Medical Group Management Association.

In other words: When a primary-care physician requests a consult from a pulmonologist, the specialist isn't responsible to make sure the PCP's files include that request in writing.

But CMS officials still insist that the requesting physician has to document the request for a consult, as CMS stated in last December's Transmittal 788. The only change is that the consultant doesn't have to verify that the initiating doctor has done so.

So, what will happen if the carrier audits the consultant and doesn't find any request documented in the PCP's files? Will the specialist still get paid? At this point, CMS hasn't been able to answer that question.

"It is a real paper chase for the consultant to have to look at the referring physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif. CMS should delete the requirement for the requesting physician to document the request for a consult altogether, she adds.

The issue isn't resolved: CMS officials say they're not planning to clarify the consult issue any further--unless providers or carriers indicate that they're still having problems. CMS doesn't even plan to put out a transmittal or manual update spelling out this latest clarification partly letting consulting physicians off the hook.
 
Best advice: As always, you should let documentation guide your coding. Now more than ever before, the consultant must have a reason and request for a consult documented in the patient's medical record, along with an opinion rendered by the consulting physician, with a written report sent to the requesting physician.

Experts also recommend adding the "fourth R" of returning (or discharging) the patient back to the requesting physician when the episode of care is complete. Remember: The "return" does not always occur at the end of the consultative service. The consultant is permitted to initiate treatment, when appropriate, and still report a [...]