Cardiology Coding Alert

Executive Summary: In a large group practice, its quite common for a non-invasive cardiologist to request a consult from their interventional or electrophysiologist (EP) colleagues. Can every consult be coded 99251-99255 (initial inpatient consultation), instead of using the inpatient subsequent care codes (99231-99233)? If so, the specialty group could significantly increase its revenue. On the other hand, it could also risk the wrath of auditors. This article will carefully analyze this question as well as look at interpretations of the Health Care Finance Administrations (HCFA) payment policy.

Like many of our readers, Paula Harrison, coder at The Cardiovascular Specialists in Memphis, TN, wrote to ask us how to code for the consulting services within the same practice between subspecialists and general cardiologists.

Suppose one of our general cardiologists is following a hospitalized patient for unstable angina. But the patient develops arrhythmia, so the general cardiologist asks our EP for a consult. How do we charge for the subspecialists services? As a consult or a hospital inpatient code? she asks.

Cynthia Chu, RN, office manager of Cardiology Associates, Inc., in Honolulu, has a similar problem. She inquires, One of our four cardiologists has additional training in peripheral vascular disease. When one of our other cardiologists refers a patient to him for claudication/peripheral vascular disease, do we bill a 99244 (office or other outpatient consults) or 99215 (office or other outpatient visit)?

The answers to both questions depend on the interpretation of Item C in the Medicare Carriers Manual Section 15506: Consultations Requested by Members of Same Group.

The paragraph states: Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation code are met.

Tip: You can download this section from www.hcfa.gov. Go to Medicare, Professional/Technical Information, Medicare Professional/Technical publications, Medicare/Medicaid Manual, Download numbers 14, 15-1, 15-2, and 06.

So theres your proof. You can bill a consult by a subspecialist in addition to one by a general cardiologist within the same practice -- if the documentation for both supports the criteria of a consultation.

But thats a big if, warns Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC. The documentation of both requesting and consulting cardiologists have to meet the criteria. If it does, Medicare should pay for the consult, she stresses. But if the documentation doesnt meet the criteria, then you should not be billing it. The fact is that many consultations being billed are not true consults.

Thats why a thorough understanding of the criteria is vital. It will determine whether your practice can ethically increase its reimbursement by billing subspecialty consults or whether it will trigger an audit and potential fines, she says.

Stradley reviews the criteria for charging a consult as outlined in Item A, Section 15506, and gives the following advice:

1. Request for an opinion.

The requesting physician (in our case example, the general cardiologist) requests an evaluation from the consulting physician (subspecialist).

A consult means the subspecialist is asked to provide an opinion on how the general cardiologist should care for that particular condition, not how the subspecialist will care for it, she explains.

For example, if the general cardiologist asks the subspecialist to recommend a change in treatment that the general cardiologist will continue to manage, then the subspecialists opinion is a consult. If the requesting physician asks the consulting physician How else can I deal with this condition within the scope of what I am doing, and the consultant provides that information, then you can also bill a consult, Stradley confirms.

But if the general cardiologist knows that he or she does not have the skills or expertise to treat the problem, and is asking the subspecialist to handle that portion of the patients condition, then you can not bill a consult for the subspecialists services.

If the general cardiologist knows the patient has a rhythm problem and is not responding to treatment, and that the only option is a pacemaker which can only be done by an EP, that is considered a transfer of care, she explains, because the EP is going to perform the procedure.

2. Report of findings.

The consulting physician should report his or her recommendations back to the requesting physician in writing, and it should be placed in the patients chart.

This is one of the most important parts of intra-practice consulting, explains Sheila Sylvan, principal of IMPACT Medical Consulting in Atlanta. Just because the doctors are right down the hall from each other doesnt mean the subspecialist can neglect writing a formal report rendering his or her opinion.

3. Management of care.

To justify a consult, the requesting physician must also retain management of the patient for the particular condition advised upon by the consultant.

Government Terms Confuse, Not Clarify

However, the line between a consult and transfer of care is often blurred because Item A in the Medicare Carriers Manual, Section 15506 does say that a consulting physician may initiate diagnostic and/or therapeutic services. But then the last line of Item A confuses the issue, Stradley points out, by citing HCFA However, when the referring physician transfers the responsibility for treatment to the receiving physician, at the time of the referral in writing or verbally (i.e., following the request to evaluate and treat), the receiving physician should not continue to bill a consultation code.

Its that word continue that confuses everyone, she says. If care is transferred at the time of the referral, the subspecialist wouldnt be continuing to do anything. This would be the first time he or she saw the patient.

The next sentence of Item A perpetuates the confusion. He or she would bill a subsequent hospital care code (99231-99233) in the hospital setting or an appropriate established patient code in the office setting (99212-99215).

Understandably, many subspecialists, who have never seen
this patient before, question, subsequent to what?

Stradley remembers that the old way of interpreting Medicare consults was that if an admitting physician called another physician to see his or her patient, the first visit was always a consult.

But now this vague wording seems to be focusing on the intent of the call to the specialist (or subspecialist), she says. If the physician who is calling you can no longer take care of this problem, and your specialty or subspecialty is the one that can, then the basic intent is a transfer of care, not a consult.

For example, if the general cardiologist called the subspecialist because he or she knew the patient needed a pacemaker, then when the subspecialist sees the patient with the intent to fix the problem him or herself it should be coded as subsequent hospital care or an established office visit instead of a consult.

If you cant bill a consult, the issue then becomes whether to bill a new or established patient code. If the subspecialist is in your practice, your only option is to charge for an established patient visit, Stradley says. If the subspecialist is not in your practice, then the subspecialist can bill as a new patient.

James C. Blankenship, MD, FACC, acknowledges that consultations among cardiologists in the same practice is a confusing area. What is really needed is a clarification by the AMA CPT panel, and then a clarification of HCFA payment policy by HCFA, says the chair of American College of Cardiologys (ACC) coding and nomenclature committee.

Tip: Even though Section 15506 states that Medicare will reimburse consultations by physicians in the same group, carriers in different states may interpret this differently, warns Debbie Adams, CPC, compliance analyst for Cardiology Associates of North Mississippi. Check with your Medicare carrier for their interpretation, she advises.

Another Consulting Scenario

Harrison also asked this question: Suppose the primary care physician hospitalized a patient for a diagnosis completely unrelated to a cardiac condition. When the patient began experiencing chest pain, the primary care physician called our general cardiologist, for a consult. He performed a diagnostic cath, which showed minimal disease, wrote a prescription for the patient and prepared a letter of findings for the primary care physician. However, later in the course of that same hospitalization, the patient developed unexplained arrhythmia, so the primary physician requested a consult from our EP. After we have charged a consult for the specialist, can we also charge for a consult by the subspecialist?

If both the requests for the general cardiologist and the EP came directly from the attending physician, it is clearly two separate requests for an opinion regarding two different diagnoses (chest pain [411.1] and arrhythmia [427.91]) that require two different levels of expertise, points out Sylvan. A consult is a consult.

However, before you bill a consult for both the general cardiologist and the subspecialist, make sure the latter service is indeed a consult and not a transfer of care.

For example, the consultants written report must go back to the requesting physician with his or her recommendations. It is important to note that these are recommendations and that the requesting physician will determine whether the recommendations are carried out, she says.

So, if a primary care physician called in an EP and the specialist performed a comprehensive workup and then put in a pacemaker, Medicare considers that to be a transfer of care, not a consult.

If the primary care physician does not have the skills to fix the problem, and calls for an EP, and the EP comes in and fixes it, then you cant bill for a consult for the subspecialist, Stradley explains. Unlike the general cardiologist who evaluated the patient and rendered an opinion (which enabled the primary care physician to fix the problem), the subspecialist is treating the problem directly.

If this were the case, you would be able to bill the general cardiologist as a consult, but for the EP, you would have to use a subsequent hospital code or an established office visit.

Tips and Traps for Intra-Office Consults

Here are some questions to ask when deciphering documentation regarding consults vs. transfer of care:

1. Who had the skills to fix the problem?

Check the documentation to see if the subspecialist actually treated the patient for the general cardiologist, or if he or she told the general cardiologist how to do it.

If the general cardiologist determined the patient has a rhythm problem that needs a pacemaker, and called in the EP because he or she is the only physician in the group with the additional level of expertise to fix the problem, then you can not bill a consult for the subspecialist, Stradley explains.

However, if the general cardiologist just wants recommendations from the EP on other options that can be combined with a non-invasive treatment plan, then billing an EP consult is appropriate, she adds. If the general cardiologist is asking the subspecialist for the others opinion (i.e. how the general cardiologist should treat the patient) that is considered a consult, she explains.

But if the general cardiologist is asking the subspecialist how he or she would treat the patient, that is not a consult. The intention is what is important in making this distinction. If the issue for the general cardiologist is my patient has arrhythmia and needs a pacemaker, then subsequent hospital codes or office visit codes might be more appropriate for the subspecialist, Stradley explains.

2. What can you find in writing?

There should be two separate elements that must appear in the patients chart to justify a consultation:

Request for consult. The requesting physician (in this case the cardiologist) must request the consult from the consulting physician (in this example the subspecialist). HCFA does not specify whether the request should be in writing, but both physicians should document it in the patients chart.

Report of findings. Just as the general cardiologist must do for a primary physician, the subspecialist must also prepare a written report to the cardiologist in the same practice.

3. Who follows what condition?

If the general cardiologist continues to follow the patient for the unstable angina and asks the EP to follow the patient for arrhythmia, you cant bill for a consult.

Instead, you would bill the service rendered by the EP as an established patient. The rule, explains Stradley, is that if physicians in the same practice fall under the same specialty code, the patient is not new, but established. EPs, unlike specialists in vascular disease, do not have their own specialty code, but are considered as 06 (cardiology). If they had their own specialty code, they could bill this service as a new patient, she says.

Billing Number Difficulties

Yet even if you do meet the criteria for a subspecialist consult, you may not always get reimbursed -- at least not on the first try, notes Sylvan.

When all physicians in a group are using the same practice billing number, it makes billing for intra-office consults more complicated, she says.

Because EPs dont have their own subspecialty designation code, its not as easy to flag as a subspecialty [on the claim form], she says.

First file the subspecialty consult electronically to get a claim number established quickly. (Having a claim number expedites the appeal process. When a hard copy is filed, it is handled manually and may get lost before its processed.)

But it will probably be automatically denied on the first electronic submission because both claims have the same ID number. Then youll need to file a hard copy claim and attach a consultation report (from the subspecialist).

Highlight the important points of the report to show why the second physicians opinion was needed. Make it as easy as possible for the insurance person to understand.
For example, point out to the carrier that the diagnoses for the cardiology and the EP consult were different (i.e. 411.1 [chest pain] and 427.91 [arrhythmia]). This supports the billing of two different Evaluation and Management Services. The second diagnosis is especially pertinent; after all, an EP specializes in rhythm problems.

Sylvan suggests developing a form letter for general cardiologists to use when submitting the appeal for intra-office consults. Describe the difference between the general cardiologists and the subspecialists scope, and explain why the subspecialists opinion was needed, she says. Make sure you indicate what skills the consulting subspecialist has that the specialist does not.

For example, say As a general cardiologist, I dont do catheterization ablations for tachycardia; therefore, I needed an EP to evaluate based on his specialized expertise.

Having a form letter for each subspecialty means you dont have to reinvent the wheel every time an intra-office consult claim is denied, Sylvan notes.

Tip: Remember that intra-office consults can only go in one direction: toward more, not less specification. For example, a general cardiologist can request an opinion from a subspecialist, but a subspecialist cant request one from a general cardiologist and bill it as a consult. You can go up the consulting tree to more defined branches, but not down it, Sylvan notes.