General Surgery Coding Alert

Question: An internist requested a consult for an elderly patient with lower gastrointestinal (GI) pain and bleeding. The surgeon evaluated the patient and scheduled a sigmoidoscopy the following day. Can we bill a consult even though the physician has scheduled a procedure?

Washington, D.C., Subscriber

Answer: As long as the internist submitted a written request for the surgeon's opinion and the surgeon provided a report of his or her findings, the surgeon may report a consult for the initial meeting with the patient. If the physician assumes care for the patient's condition following the initial visit, however, you should report all subsequent visits for the same condition using the appropriate established patient code.

In the past, some payers have not reimbursed consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans (or, in this case, ordering a sigmoidoscopy). In July 1999, HCFA (now CMS) transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the physician initiates treatment, as long as the doctor meets all consultation criteria and no transfer of care occurs.

The Medicare Carriers Manual (MCM), section 15506, further explains, "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance" [emphasis added]. "Referral," in this instance, is simply another term for transfer of care.

If a transfer of care does occur, "The receiving physician would report a new or established patient visit, depending on the situation and setting (e.g., office or inpatient)," according to the MCM. And, although "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms in connection with a consultation. Auditors and payers may automatically consider "referral" or "treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming complete care of the patient, and therefore may not reimburse for a legitimate consultation.