Medicare Compliance & Reimbursement

You've been on the fence for two years now on consultation coding for a specific problem, and CPT 2008 didn't answer any of your questions. But you can confidently code a consult despite the "transfer of care" language if the encounter passes this litmus test.

In 2006, CMS redefined a transfer of care as one that occurs "when a physician or qualified NPP [nonphysician practitioner] 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."

The revision caused confusion over whether cases in which a physician sees a patient at the request of another physician for care of a specific condition could qualify as a consult.

"The answer is yes and no," says Patrice Morin-Spatz, coding expert with Med-Books in Richardson, TX.

Solution: "It's yes if the scenario can pass this two-prong test," says Morin-Spatz, past-editor of the AMA's CPT manual. When considering a consultation code, ask the following questions:

1. When is the diagnosis reached?

2. When did treatment begin?

Key: You may consider the visit a consultation when the diagnosis or the treatment is not known, provided the requesting physician words the request for opinion appropriately. Documentation should show that he asks for either a diagnosis or a treatment plan.

Apply the above two questions to this scenario: A physician sends a patient who has had frequent ear infections to an ear, nose and throat (ENT) specialist for possible ventilating tube insertion.

Does the initial visit's request qualify as a consult? "It depends on what the physician is asking for in his request to the ENT," Morin-Spatz says.

The visit can qualify as a consultation if the requesting physician knows the condition and is asking for the ENT's opinion relative to a treatment plan, Morin-Spatz says.

Example 1: The physician's request states, "I think my patient may be a candidate for ventilating tube insertion. I'm sending him to you for your opinion on possible treatment options."

In this case, the diagnosis is known, but the treatment hasn't begun, Morin-Spatz says. "Therefore, the ENT is truly rendering an opinion."

If the initial ENT encounter meets the other consultation criteria, including a report back to the requesting physician, you may code the visit with 99241-99245 (Office consultation for a new or established patient ...).

Best practice: The ENT can further stress that he rendered an opinion by using "requesting" terminology in his report, says Barbara J. Cobuzzi, MBA, CPCOTO, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, NJ. A good statement would be: "Thank you for requesting my opinion on Mary Smith's chronic rhinitis," she says.

Requests specifying the treatment may fall short of a consultation.

Example 2: The physician's request indicates, "The patient needs ear ventilating tubes," and there are no more necessary steps in deciding the treatment. In this case, the request doesn't meet a consultation's intent for opinion, Morin-Spatz says.

Instead, the report is a transfer of care for a specific condition. The physician is sending the patient over for ventilating tubes, and the treatment plan has already been reached prior to the patient workup by the otolaryngologist, Morin-Spatz says.

Therefore, you would code an office visit (99201-99215, office or other outpatient services depending on whether the patient was new or already established).

Remember that CMS has stricter consultation guidelines than CPT. You don't have to apply CMS rules across the board.

"When dealing with [non-Medicare] payers, I tend to use the CPT definition," says Donelle Holle, RN, professional fee services manager for the University of Michigan Health Systems.

Using dual consultation coding guidelines means keeping track of which rules to follow with which patients. "When treating the patient, the doctor should not have to worry about what insurance a patient has," Cobuzzi says.

Evaluations for possible ventilating tube insertion mainly involve pediatric, non-Medicare patients. For non-pediatric issues, consider three tactics:

A. Safe way: Implement the stricter guidelines for everyone. This ensures you cover all bases and that nothing will fall through the cracks.

B. Color route: Paper offices can put a bright-colored sticker on Medicare charts so that the doctor can be aware of Medicare patients, Cobuzzi says. For non-designated -- private payer -- charts, the physician could code the encounter using CPT guidelines.

C. Policy path: Research each carrier's guidelines, and keep copies of those guidelines handy so you can reference them whenever necessary. Some practices keep a binder with all of the applicable carrier policies on consults so they can flip to the appropriate one at any time.