Consultations

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We all know that you can no longer bill Medicare/Medicaid for consultations but there are still carriers that will pay for these. We have a disagreement in our office about charging consultations. Anyone that could help clarify this.

I am not sure if our problem is with the actual referral to us or when the assumption of care starts.
Example:
Patient referred to us from primary care referral states "Referred for Lt Knee bucket handle tear of entire Medial meniscus" My physician see and evaluates this patient and decides to schedule him for surgery. He wants to charge a consult.
Question:
Can he charge consult? My thinking is that he agreed to assume the care when the referral was sent with a diagnosis already on it. The PCP was sending patent because he wanted us to handle the case. Not give him an opinion an send patient back. My physician wants to disagree and states that he needed to do the consult before he could make decision to go to surgery.

AAOS states that a physician can order test and schedule surgery and still bill a consult.
CPT states that if physician assumes part or total care of the patient it is no longer a consult.

Can anyone help the confusion in our office???????
 

scooter1

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My personal opinion based on the information you have given is that it was a transfer of care.
 

OCD_coder

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I would have to agree, the PCP cannot perform a meniscectomy and appropriately "referred" the patient to an orthopedist for surgical care. Consults are very hard from and outpatient office perspective for an orthopedic office. Typically consults are limited to ED encounters, but not exclusively.
 

dclark7

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This has been a source of conflict between PCPs and specialists for years. Your physician is incorrect, he did not have to perform a "consult" to determine the need for surgery, he had to perform an "evaluation". Since the PCP had already determined the problem and sent the patient for treatment and not his "opinion" there is no consult.

When discussing the differences with one of my docs, the light bulb went on and he said "I get it, if they want me to tell them what's wrong with the patient because they're not sure it's a consult, if they already know and they're passing the torch it's not." Maybe this is how you can approach it with your doctor. In this case the PCP was passing the torch.
 

melzinser

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Well said!

Very well put, Doreen.

In the example you use, the patient has a definitive diagnosis and came to your doc to get it fixed. The"grayest" area is when they come to our ortho docs to discuss a different treatment option for a known condition, say, minimally invasive rather than traditional surgery, or pain management versus spine surgery. And at the time of the visit the patient decides to stay with us and follow our recommended course of care. It certainly started as a consultation, but does it change by the end of the visit? Can we consult AND schedule the patient for a procedure? I feel in these cases the answer is 'yes'.
 
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