Is this legal?!!!


Levittown, NY
Best answers
I'm having a probem explaining to my office manager about the rules of billing a consult. I work in a Rheumtaology office and 8 months ago I told the office manager that we should not be billing consults unless we have a written request from the patients doctor. She told me I was wrong because we are a specialist and and the doctors are writing a consult letter to the referring doctor. I showed her 3 forms of proof that she was wrong. Well she finally found out that I was right when she went to a Medicare meeting and they showed her the rules of abilling a consultation. Now what she has the front desk doing is faxing over consult requests to all new patients doctors that come in that don't have a written consult from their doctor. She is doing this for Medicare patients and the commerical insurances as well. I want to know is this legal? proper?. I am to hold all billing sheets that have consultation levels circled until they get this consult request from these patients doctors. I am the only ceritified coder in the office. Any answers on this practice?
I feel if there is no written request for a consult we should be billing a new patient. I think she is just money hungry and I don't want to loose my certification because of her greed. Is there anything I can do? Any suggestions?
Thank you
A fax is ok, even a phone order. As long as the request is documented in the patients' chart. Way to watch your back though. I just left a Cardiology clinic where they were nothing but greedy! Now I audit E&M, and educate. Much better.
I would contact your local Medicare carrier about that. My gut instinct is that it isn't appropriate -- If the doctor didn't ask for a consult, you shouldn't be telling them they have to ask for one! -- But, I don't know of any specific reference off-hand. I do know that your local carrier should be able to provide you with a refence and/or a written response to the question.
Are they really consults, or are they just referrals? It seems like the two are confused alot. If the doctor is transferring care to the rhuematoid phyisican, then this is just a referral. In order for it to be a consult, the doctor needs to be requesting an opinion or some sort correspondence or something from the specialist. I work for a specialist too and it seems like they think that everytime family practice sends someone over that this constitutes a consult and that's just not the case. We've pounded that into their heads so much, I think they've finally gotten the picture, so don't give up, keep questioning things that don't sound right to you, you don't want your "neck on the chopping block."
This does sound much more like soliciting a consultation--which might be addressed in Stark Law. I'm not expert and my references on that topic not in-depth enough to cover the area.

Ditto on the comments above: contact someone at your local level of CMS and continue to think critically on what "standard" practices are putting your facility at risk.

Good luck to you. Another idea is to submit it to the Compliance Guru in the Coding Edge.
I have the same question in terms of an Colon & Rectal surgeon office, Primary care doctors send their patients to us for screening colonoscopies. We have them come in for an office visit (which should be billed as what? consult or new patient) do a moderate history with no physical and then they get scheduled for their scope at an ambulatory surgical center. Is this a consult or new patient office visit? Sometimes they come with an consult request for the screening colonscope, sometimes not.
The request for a consultation can be written, faxed, or just over the phone. If the pcp doctors are sending their patients to your doctors and just not sending written proof of the consultation request, then I would say it is ok for you to fax over a form for them to fill out so that you have something in your charts. That is of course if these are all truely consults not referrals.
These faxes that come back from these doctors are just stating: joint pain,RA some come back blank with just a signature. Nothing stating they are sending this pt for a consult with a written Dx. When a new PT comes into the office with out a note from their Doctor asking for a consult they ask the PT who their PCP is and then our office faxes over a consult request form to that pcp so we can bill a consult. Thats what I'm having a problem with understanding if this is proper. The request for a consult is on our letterhead not the PT's doctor letterhead or RX pad.
It doesn't sound like these patients are being sent for consults at all. It sounds like they are just being sent by their PCP to a specialist for treatment - AKA Transfer of Care. It doesn't seem appropriate to try to be billing for consults. Again, I don't know of any specific guidelines about soliciting consults, but the IOM is pretty clear on the difference between a consult and a transfer of care.