Control of Care Determines Who Can Bill for Consultation
Published on Sun Oct 01, 2000
Nearly a year after Medicare tried to clarify its definition of consultations, many gastroenterologists are still having difficulty deciding whether the evaluation and management (E/M) service that they render to a patient in the emergency department (ED) is a consultation. The sticking point seems to be how to determine whether the services provided by the gastroenterologist represent a transfer of care.
One of the reasons this is such a problem with all physicians is that a consultation among physicians is different than the CPT definition of a consultation, says Charla Prillaman, CPC, a senior coding consultant for Webster, Rogers & Co., a multispecialty healthcare consulting firm in Florence, S.C. For some physicians, a consultation means help me out with this, but the CPT definition requires that a certain kind of service takes place where the original physician retains some care of the patient.
Three Rs Must Be Met
When talking about consultations, coding professionals frequently refer to the three Rs that must be met, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.
1. The request: The ED physician must make a request in writing to the gastroenterologist, soliciting his or her opinion on the patients condition. This request also should include the reason or medical necessity behind the consultation. Medicare guidelines state that a simple entry in the emergency departments common medical record for the patient is adequate.
2. The review: The gastroenterologist must review the patients condition, documenting the three components in the patients medical record. All three of these key components of an E/M visit (history, examination and medical decision-making). These will be considered when determining the level of consultation.
3. The report: After the review of the patients condition, the gastroenterologist must issue a written report to the ED physician about the patients condition. A copy of the report should be filed in the patients medical record.
No Consultation if Care of Patient Is Transferred
Having met these three requirements, however, does not guarantee that the E/M service was a consultation. Many times the gastroenterologist will meet all these requirements, says Brink. But if the gastroenterologist ends up taking over the care of the patient, then you probably dont have a consultation.
CPT doesnt address the issue of transfer of care during a consultation except to state, A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.
Medicare, in an effort to clarify its policy on consultations, revised its instructions to carriers in August 1999 by stating, Payment may be made regardless of treatment initiation unless a transfer of care occurs. The instructions continue, A [...]
