Understanding Consultation Guidelines
by Erica Schwalm
February 11, 2006
If you have any questions about the correct way to bill for or document a consultation, now is the time to brush up! CMS updated their consultation guidelines effective January 1, 2006.
What is a consultation?
A consultation is an E&M service provided by a physician (or qualified NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician (or other appropriate source).
A patient referred to your practice for evaluation and treatment of a problem is not necessarily a consult.
In fact, when documenting consultations, remove the word “referral” from your vocabulary; a referral implies a transfer of care to many, and when a transfer of care occurs, you can not bill for a consult.
A consult should only be billed if the requirements are met. Remember the “3 Rs” of a consultation:
Out of the “3 Rs”, the request is the area that causes the most confusion and is the area of documentation that most often is lacking. You may be performing the consultation according to the guidelines, but if your documentation doesn’t back it up, you could face take backs and risk being put on pre-payment reviews by Medicare.
Don’t wait until
Medicare asks for records to understand the guidelines and improve your
documentation.
What is a transfer of care?
A transfer of care occurs when a provider requests that another provider take over the responsibility for managing
the complete care of a specified condition and
does not expect to continue treating or caring for the patient for that
condition. The requesting physician is not seeking an
opinion or recommendation to personally treat the patient and does not expect
to provide any treatment for that condition.
The receiving provider must document this transfer in the patient’s
record and report the service with the appropriate new or established patient
visit code depending on POS and level of service performed. The receiving physician can not report a consultation service.
Example:
Mary
Jones goes to see Dr. Gyn for her annual GYN exam. Mary tells Dr. Gyn that her left foot has
been bothering her. Dr. Gyn tells Mary
she has a bunion and should go see Dr. Foote, the podiatrist, for evaluation
and treatment of this problem. Dr. Gyn
does not expect to be involved in the management of this problem any further
and does not request any recommendations from Dr. Foote. Dr. Gyn writes a referral for Mary to see Dr.
Foote. Dr. Foote should bill a new
patient visit when he sees Mary, not
a consult.
MYTHS & TIPS
MYTH #1: I am a specialist, so all new patients are consults.
In the example above, Dr. Foote is a specialist, but he could not bill for a consult. In order to bill a consult, another provider must be requesting your opinion or advice. The request can be made verbally or in writing, but must be documented in the patient’s record by you and the requesting physician.
√ TIP:
CMS does not specify how the request should be documented, only that “A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified NPP's plan of care in the patient's medical record”.
Given this, there are several methods you can utilize to document the request for consultation and reason for consultation; here are two examples:
1. When verbal requests are received, it should be sufficient to document this in the patient’s medical record by notating who called, when, and the reason. Example: Dr. Miller called at 2:30 p.m. on 2/10/06, to request a consult for John Smith’s herniated lumbar disc. Or, in your written response to the requesting physician you can make a statement, such as, “Per your telephone request on February 10, 2006, I saw your patient, John Smith, today for consultation regarding his herniated L4-5 disc.”
2. You may prefer having written requests. In this case, you may ask the requesting provider to furnish you with one, or if this is not something you are comfortable with, you can provide the requesting provider a simple form via mail or fax that they would sign and send back.
Example:
|
Your Letterhead Here Patient Name:
___________________________________________
Date of Request: __________ Requesting Provider’s Name:
________________________________________________________
_________________________________________________________________________
_________________________________________________________________________ _________________________________ Signature |
MYTH #2: If a
patient is referred to me, I can bill for a consult.
A referral is not a consult. The problem with the word “referral” is that is can mean different things to different people. Often times, a “referral” is a managed care requirement. It is usually a form filled out by a patient’s PCP (primary care physician) so that the managed care organization will “allow” the patient to be seen by a specialist. This referral itself does not meet the CMS requirements for a consultation. Also, many providers use the term “referral” any time they send a patient to another provider. If a patient presents to your office because they were referred to you by Dr. Smith you can not automatically bill a consult. A formal request and reason for request should be made to you. If the intent of the requesting physician is not clear, you should seek clarification. The form letter example above can be used also for this purpose. If this is not done, an auditor may say the referral was a transfer of care and, therefore, does not meet the requirements for a consultation.
See next page for some of the consultation guidelines. January 2006 changes are highlighted in red. For complete guidelines, see http://www.cms.hhs.gov/transmittals/downloads/R788CP.pdf
For questions, contact your local Medicare carrier.
Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners
30.6.10 Consultation Services (Codes 99241- 99255)
(Rev.788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)
In part, for complete guidelines, see: http://www.cms.hhs.gov/transmittals/downloads/R788CP.pdf
“A request for a consultation from an appropriate source and the need for consultation
(i.e., the reason for a consultation service) shall
be documented by the
consultant in the patient's
medical record and included in the requesting physician or qualified NPP's
plan of care in the patient's medical record; and
After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.
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.”
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“A transfer of care occurs when a physician or
qualified NPP requests 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.”