Latest Medicare Clarification on Consultations Gets Mixed Reviews
Published on Wed Sep 01, 1999
Cardiologists, like all medical specialists, often are called on to share their expertise with an attending physician. However, a series of previous clarifications by Medicare regarding what constituted a consultation (99241-99275), as opposed to a transfer of care, did anything but clarify the issue for many cardiologists.
A new Medicare revision, however, may be a step in the right direction. According to Transmittal No. 1644, which was issued on August 2 and went into effect August 26, a consult may be billed regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.
According to some coding experts, the newest revision means the physician performing the consultation now can initiate therapeutic as well as diagnostic treatment on the same day, as long as complete care of the patient has not been transferred, and the cardiologist is not simply following the instructions of the requesting physician.
Note: If, for example, a family practitioner (FP) sends a patient to a cardiologist and specifically requests a stress test, that would not be considered a consult, because the cardiologist is following the FPs instructions.
Cynthia Swanson, RN, CPC, a management consultant with Seim, Johnson, Sestak, Quist, LLP, an accounting and healthcare consulting firm in Omaha, NE, describes the revision as a big step in the right direction.
The revision helps makes it much clearer to Medicare carriers that even though the cardiologist is initiating diagnostic services, he or she is still performing a consultation, Swanson says, adding that the revision brings Medicare closer to the definition of a consultation in CPT 1999, which clearly states that a physician consultant may initiate diagnostic and/or therapeutic services.
What Medicare had interpretedand it was reflected in their carriers reimbursementwas that if the cardiologist took over any aspect of managing the care of the patient, it wasnt a consult, it was a referral, she explains. With the revision, Medicare carriers have a clearer idea of what Medicare meant by transfer of care.
To illustrate the effect of the revision, Swanson cites the example of a family practitioner who sees a male patient complaining of chest pains and difficulty breathing when he exercises. Suspecting cardiac problems, the family practitioner sends the patient to a cardiologist, who then takes the patients history and gives him a physical. The cardiologist then contacts the FP to say that the patient needs a thalium stress test. The results of that test, explains the cardiologist, will determine the patients course of treatment and, therefore, whether a transfer of care [...]
