Medicare Compliance & Reimbursement
Don't Cut The Requesting Doctor Out Of The Loop
Good news: One carrier issued a new "frequently asked questions" (FAQ) item on the confusing issue of consults. A provider asked Palmetto GBA a straight question, and Palmetto managed to give a straight answer.
The question: Can a provider start additional testing or treatment at an initial consultation and still have the visit considered a consult?
Palmetto's answer: Yes. A physician or qualified non-physician practitioner can start diagnostic services and treatment at the initial consult or a subsequent visit. But you shouldn't bill for "ongoing management" after the first consult using consultation codes. Instead, you should bill for later visits using the subsequent visit codes.
Palmetto does include one cryptic sentence at the end: "Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs." And of course Palmetto doesn't define "transfer of care."
Still, the Palmetto clarification is helpful, say experts. "Any time physicians initiate treatment, they are still in okay territory to bill a consult," says Quinten Buechner with ProActive Consulting in Cumberland, WI.
"Patients are sent for evaluation, and part of that evaluation may be to order a test to confirm the evaluation and establish a diagnosis," says Heather Stecker with Cardiology Consultants of Philadelphia. "Any future services made or follow up appointments should be established visits," she adds. "It is all about the intent of the visit."
For example: Dr. X, a primary care physician, sends a patient to Dr. Y, a cardiologist, to "evaluate the new onset of chest pain and shortness of breath to determine if there is a cardiac etiology." This is a consult because Dr. X wants Dr. Y to evaluate the patient. Dr. Y can order an echo study and EKG.
For a consult to be valid, Dr. X must sign off on all medical care related to the reason for the consult, notes Jim Collins with the Cardiology Coalition in Saratoga Springs, NY. "To be safe, consulting physicians should echo the request for a consultation as their chief complaint in every visit note they will be billing as a consultation," Collins adds. Consultants should also send a report to the requesting physician.
But if Dr. X sends the patient to Dr. Y to manage his chest pain and shortness of breath, then this means a transfer of care has happened, says Stecker. You should bill a new-patient visit (99201-99205).
The Medicare Claims Processing Manual (Chapter 30) says that a transfer of care is an agreement between two doctors for the specialist to take over the patient's care, notes Buechner.
After an initial consult, Dr. Y can give more treatment recommendations, and then Dr. X can decide whether to transfer the patient's care to Dr. Y, notes Rena Hall with Kansas City Neurosurgery.
Medicare Compliance & Reimbursement
- PART B:
Avoid Reporting 99211 For Diagnostic Testing Services
Audiologists should be heard and not seen (by your doctor).
Myth: Audiologists should bill "incident to" [...] - CONSULTS:
Don't Cut The Requesting Doctor Out Of The Loop
Treatment, tests don't mean the visit's not a consult.
Good news: One carrier issued a new [...] - NPIs:
Now's The Time To Double-Check Your Information In The Database
Hurry up and wait for NPI database access.
Just when it seemed like your troubles with [...] - CMS TRANSMITTALS:
Make Sure Each NPI Matches Up To Only One UPIN -- Or You Could Be In For Headaches
Medicare could auto-deny 100 percent of suspicious claims.
Watch out: Medicare's Program Safeguard Contractors (PSCs) will [...] - CODING:
No Modifier Will Save You From New Digestive Surgery Edits
Watch your laparoscopy coding on the same day as surgery.
The latest version of the Correct [...] - CRITICAL CARE Here's What You Need When Reporting Critical Care -- And What You Don't
Dodge critical care mistakes by dispelling 2 myths.
A physician can provide critical care just about [...] - CCI 13.2:
CCI Grants Relief From Spinal Surgery Edits
Also, check out this modifier change for reporting 38745 with 19303.
CPT 2006 gave you some [...] - REIMBURSEMENT:
Do You Know The Critical Ingredients For A Successful Critical Care Claim?
Test yourself with this sample scenario.
Now that you've busted the below two critical care coding [...] - HIPAA COMPLIANCE:
How To Write A Business Associate Contract
Where to go to see a sample doc.
If you find yourself flummoxed when confronted with [...]
