Medicare Compliance & Reimbursement

But consult confusion will continue into next year.

What's the difference between a consult and a transfer of care? The experts still aren't sure.

The CPT Editorial Panel failed to reach a consensus on how to clarify the definition of consult at its February meeting, according to the Physician Regulatory Issues Team (PRIT) at the Centers for Medicare & Medicaid Services (CMS). That means there won't be any clarification in the CPT 2008 update.

CMS was hoping the CPT update would settle some of the confusion that the agency created with Transmittal 788, according to William Rogers, the PRIT's head. "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 patients' complete care for the condition and does not expect to continue treating or caring for the patient for that condition," CMS wrote.

That sentence worried many physicians, who thought that CMS was barring them from sending a patient to a specialist for a consult, and then allowing the specialist to treat one specific condition.

CMS could still clarify the consult issue itself with another transmittal, but "things have really slowed to a crawl" with preparation for next year's physician fee schedule rule and other rules, Rogers notes. He and another CMS official spoke to the American Academy of Nurse Practitioners in early April and "got beat up about the consult issue." So they're aware that "people would like to see a clarification sooner than later."

You're not likely to receive a denial based on this issue, but it could present a problem in an audit, Rogers notes. So far, he hasn't heard of either the Recovery Audit Contractors (RACs) or the carriers auditing providers' consults.

The answer to all of these consult questions won't come until the HHS Office of Inspector General "hires a new fresh-out-of-college accountant" to audit your consult billing based on having just read the rules, notes Quinten Buechner with ProActive Consulting in Cumberland, WI.

The rules, as written now, are confusing enough that you could get into a lot of trouble if you're not careful, Buechner adds.

What to do: If a physician sends a patient to your physician for a consult and your physician decides to treat the problem, send the requesting physician a letter first. The letter should explain the patient's problem and state that the two physicians have agreed that the specialist will take care of it.