General Surgery Coding Alert

General surgeons are often asked to share their expertise with an attending physician. However, a previous series of clarifications by Medicare regarding what is and is not a consultation has done anything but clarify the issue for many surgeons.

Now a new Medicare revision (8199) may be a step in the right direction. According to Transmittal No. 1644, which recently when into effect, 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 new revision means that the physician performing the consultation can now 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 general surgeon is not simply following the instructions of the requesting physician.
Others say that until the definition of complete care is resolved, the issue will continue to fester.

A previous revision issued in June 1998 also stated that a consultant could initiate diagnostic or therapeutic services, but muddied the waters by stating that the visit could not be billed as a consult if partial or total care of the patient had been transferred. That meant that some carriersMedicare and commercialwould not pay for a consult if any aspect of the patients care was being managed by the specialist.

By clarifying when a transfer of care occurs, the new revision also 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.

Some coding experts maintain that the distinction between partial and total, or complete, is significant and makes it easier to defend the use of the consult, because they define total care as taking over all aspects of a patients treatment, including exams and services unrelated to the diagnosis that spurred the request for a consult. But others maintain that total care applies only to the condition the requesting physician sought advice for, and therefore, if the specialist initiates treatment for that condition, some carriers could interpret that as complete care.

Under HCFAs revised guidelines, the basic requirements of a consult are:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate
source and the need for consultation must be
documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

Note: The request for a consultation, as well as the response, should be retained in the patients files in case Medicare asks to see it subsequently.

Documentation Critical to Justify Consult

There are a lot more problems with coding for consultations than simply the question of what constitutes a transfer of care or complete care, according to Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL, which specializes in general surgery coding and billing.

The new clarification may define it better for people who in the past may have questioned the meaning of transfer of care, Bonner says. But everyone seems to have gotten away from what really needs to be said about consults, which is that the documentation requirements are rarely there.

At a high level of service (99244, office consultation for new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity; 99245, medical decision-making of high complexity; 99254, initial inpatient consultation, comprehensive history, comprehensive examination and medical decision-making of moderate complexity; and 99255, medical decision-making of high complexity), the documentation must support all three components, she says, which can be difficult.

The general surgeon often says, Its always a consultation the first time I see the patient, because I dont know whether Ill be taking over treatment, and that makes sense until you see the documentation, Bonner says. If the documentation says Patient came to me for hernia repair, that may be interpreted as a transfer of care, she says, because the only reason he is being sent to the specialist is for the treatment of the hernia.

Bonner points to a general surgeons consultation report that clearly indicates a referral for surgery that would likely be rejected if claimed as a consult. In it, the surgeon says he was asked to see the patient in surgical consultation for placement of an Infuse-A-Port. In this situation, the attending physician clearly has instructed the surgeon and, therefore, the visit would not qualify as a consult.

She also notes other reports that fail to indicate the identity of the attending physician; in those situations, too, a consult should not be billed.

Note: Use of the word referral should be avoided, as this indicates a transfer of care. The attending physician should be considered as such, or as the requesting physician; otherwise, your carrier may assume that the surgeon has taken over care of the patient who was referred. Even Medicare uses the term incorrectly at times; for example, in the August revision, the term referring physician is used several times even though a consult is being defined.

Be Cautious of Overuse

For Bonner, the new clarification is not a big change, but she worries that it will convince general surgeons to bill consults even when they are not appropriate and that this will spur more audits.

There is no difference at all in the new language. All along, Medicare guidelines stated you could initiate treatment on the first visit and even do follow up. So in my opinion, the language hasnt changed, and it shouldnt be used to justify more consultations in the future, because thats not its intent, she says, noting that when modifiers

-25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and -59 (distinct procedural service) were clarified, they were overused, audits ensued, and some carriers began to routinely deny every claim with those modifiers.

If the clarification defines the consult guidelines in plain English, thats great, but if consults are misused, the government will start to nail us next year. Theyll say we misinterpreted their memo, she says.

Cynthia Thompson, CPC, a senior coding specialist with Gates Moore and Company, an Atlanta-based consulting firm, agrees that the clarification merely confirms what Medicare has said before. But she also thinks the change will benefit general surgeons and other specialists because it will help eliminate some of the confusion and uncertainty surrounding the billing of consultations.

Although Medicare has previously stated that a physician consultant may initiate diagnostic and/or therapeutic services, they now have come out and defined that as partial care of the patient, Thompson says. She says the biggest effect of the revision will be to require Medicare carriers across the country to interpret consultations differently. However, Thompson notes that under the new guidelines, a consultation still requires a request, in writing, from another physician for an opinion or advice regarding the evaluation and management of a specific problem. Also, the consultants opinion must be communicated in writing to the requesting physician.

And she says that commercial carriers may still continue to deny a consult if it is done on the same day of the procedure, regardless of the HCFA clarification.

Thompson recommends that requesting physicians create a simple consult request form to help clarify the intent of the request. The form would include a request for the patient to see the consultant physician, the patients diagnosis and the time range when the patient should be seen. It also would indicate whether the appointment was

1) a consultation or
2) a referral for treatment and/or management.

She says that the form protects both the requesting and consulting physicians by documenting in writing the reason for the appointment with the specialist.

Thompson also suggests that a member of the consulting surgeons staff call the requesting physician to indicate that treatment is going to be initiated. Even though such a call is not technically necessary before the consultant begins treating the patient, Thompson says documenting the call to let the requesting physician know what is going on is a good idea.

Use Caution When Billing Consults

Other reimbursement specialists are not so sanguine about the effect of Medicares latest change. Everybody is excited about the revision, but the question of what constitutes complete care of the patient is still unanswered, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, SC, who was recently named Coder of the Year by the American Academy of Professional Coders.

She warns general surgeons not to get too relaxed about billing consults under the new guidelines, noting that the revised descriptions in Sections A and B of 15506 contradict the unrevised wordage elsewhere. Callaway-Stradley cites the guidelines for consults during postoperative care provided in Section G, and says the definition of transfer of care provided there differs from that in Sections A or B.

According to Section G: If the surgeon asks a physician who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patients condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physicians opinion or advice for the surgeons use in treating the patient. The physicians services would constitute concurrent care and should be billed using the appropriate-level visit codes.

In other words, Callaway-Stradley says, the persistent problem of reconciling one long-standing definition of a consultas an opinion or advice onlywith treating the patient has not been satisfactorily resolved and will likely be interpreted differently by various Medicare carriers.

Callaway-Stradley points out that Medicares June 1998 revision, which indicated that a consultant may initiate diagnostic and/or therapeutic services, left the question of transfer of care unanswered. The latest revision, she says, tries to resolve that issue, but fails to define complete care. Until that is resolved, she says, general surgeons can expect more confusion over whether to bill for consults.

Already, there are reports of carriers denying consults since the newest Medicare clarification (1644) was issued. These carriers maintain that if the specialist treated the patient during his or her first visit, that constitutes a complete transfer of care, and they deny the consultation.

Meanwhile, coding experts on both sides of the issue expect that continuing pressure from specialty medical associations will spur yet another revision of this thorny issue in the Medicare Carriers Manual.