Transfer of Care vs. Consultation

mwerley

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When does a transfer of care occur? If a practitioner requests a consult for a particular condition and expects us to treat them for that condition isn't that a consultation? In the Medical Economics April Issue its states "that if a physician is taking over the care for the condition that the originating physician referred, then a consultation cannot be billed." In the AMA CPT Code book it clearly states "A consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician." It goes on to say "In the hospital or nursing facility setting, the consulting physician should use the appropriate inpatient consultation code for the initial encounter and then subsequent hospital or nursing care codes. Same statement for the office setting. QUESTION: Should'nt we be able to bill an initial consultation and then any subsequent visits if not in a global period?
 

RebeccaWoodward*

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Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules;

The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

Transfer of Care

A transfer of care occurs when a physician or qualified NPP requests (not seeking an opinion-emphasis mine) that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.
In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.10

Answer to question...Yes

In the office or other outpatient setting, following the initial consultation service, the Office or Other Outpatient Established Patient codes (99212 – 99215) shall be reported for additional follow-up visits. In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231 – 99233) shall be reported for additional follow-up visits.
 
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Short answer

Rebecca, as always, has the exact links for the "official" response.

But to make things simple ... You ask: If a practitioner requests a consult for a particular condition and expects us to treat them for that condition isn't that a consultation? (emphasis added by FTB)

I think the key here is "expects us to treat them" .... if the original practioner is sending a patient to you to be treated for the condition, he is NOT requesting your advice/opinion on the management of the condition. He is saying, in effect, "here, you deal with this." That's a transfer of care.

If the original practioner requested a consultation (that is, asked "what do you think about this problem?") then you have a consult. That would be true even if as a result of the consultation your physician determined that the patient needed additional diagnostic tests or surgical treatment, and ordered or scheduled those services.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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