General Surgery Coding Alert

Question: Can I still report a consultation code if the "consulting" physician initiates treatment, or does that constitute a transfer of care and thereby require that I report a standard outpatient (for the office) or inpatient (for the hospital) code?

Colorado Subscriber

Answer: A consulting physician can initiate treatment and still report a consultation code (99241-99245, office; or 99251-99255, initial inpatient) as long as the service meets all the consultation requirements (the consulting physician receives a request and reason for a consultation, then renders his opinion and provides a report of his findings back to the requesting physician).

CPT makes this point clear, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." CMS has long followed this guideline and has reiterated it several times over the years.

In July 1999, CMS transmittal R1644.B3 clarified that Medicare will pay for a consult regardless of whether the consulting physician initiates treatment, as long as the visit meets all consultation criteria and no transfer of care occurs. The Medicare Internet Only Manual (IOM) reiterates this point, stating, "Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs."

Most recently, Part B provider Palmetto GBA issued a "frequently asked questions" item on this topic and confirmed that a physician or qualified nonphysician practitioner (NPP) can start diagnostic services and treatment at the initial consult or a subsequent visit. However, you shouldn't bill for "ongoing management" after the first consult using consultation codes. Instead, you should bill for later visits using the standard office visit (or inpatient, if appropriate) codes.

You would not, however, report a consultation if a "transfer of care" occurs.

"A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition," according to the IOM.

A transfer of care means the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition.

In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and should not report a consultation service, according to the IOM.

Example: A patient with a visible hernia in the lower abdominal area arrives at the primary-care physician's (PCP) office. The PCP immediately refers the patient to a general surgeon for treatment and repair.

In this case -- even if the PCP contacts the general surgeon to recommend he see this new patient -- the service does not qualify as a consult. Rather, because the PCP is not asking for advice on the patient's condition -- instead leaving treatment completely to the general surgeon -- a transfer of care has occurred.

The general surgeon would report the initial E/M service using an appropriate new patient code (for instance, 99204, Office or other outpatient visit for the evaluation and management of a new patient -).