Medicare Compliance & Reimbursement

Ensure you know the 5 consultation keys -- we’ll tell you what they are

Rumors have circulated that CPT 2008 will offer coders updated, clarified guidance on the difference between a consult and a transfer of care, but that guidance won’t be forthcoming in January after all.

Experts Disagree on Transfer of Care Definition

When you’re trying to code your physician’s consultation services, one of the first questions you need to ask before reporting 99241-99245 (Office consultation for a new or established patient …) or 99251-99255 (Inpatient consultation ...) is whether the requesting physician transferred the patient’s care to your physician or is asking your physician for an opinion/recommendation.

"The verbiage of the consultation guidelines illustrates that the surgeon can actually initiate treatment and order tests, but then the coder is left to ponder what would truly be classified as a transfer of care," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh and past member of the AAPC national advisory board.

Bad news: Unfortunately, the experts still can’t agree how a consult differs from a transfer of care. The AMA’s CPT Editorial Panel failed to reach a consensus on how to clarify the consult definition during its February meeting, according to CMS’ Physician Regulatory Issues Team (PRIT). 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 chairman. "A transfer of care 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," CMS wrote.

The problem: That sentence worried many physicians, who thought that CMS was barring them from coding a consult when a physician requests an opinion on a patient for a specific problem, and the specialist, your physician, then treats it. For instance, a family practitioner sends a patient who has chronic abdominal pain to your gastroenterologist for evaluation and possible surgical solutions. Does this typical scenario qualify as a consult or as a transfer of care?

CMS could still clarify the consult issue with another transmittal, but "things have really slowed to a crawl" with preparation for next year’s physician fee schedule and other rules, Rogers says.

Good news: You likely won’t receive a denial based on this issue, but it could present a problem during an audit, Rogers says. So far, he hasn’t heard of either the Recovery Audit Contractors (RACs) or the carriers themselves auditing providers’ consults in such detail.

Stress Consult Documentation Criteria

Experts say, based on the Medicare regulations, that carriers will pay for a consultation when the physician documents these five items:

• a request from a referring physician

• the reason for the request

• a patient review

• a written report to the requesting physician

• the return of the patient to the requesting physician

What to do: If a physician sends a patient to your physician for a consult and your doctor decides to treat the problem, send the requesting physician a letter first.

The letter should explain the patient’s problem, the physical findings, the diagnosis, the physician’s opinion and recommendations, and state that considering the findings and conclusions the two physicians have agreed that the physician will provide care for this problem.

You should code this initial service by the physician as a consultation using 99241-99245. Then code the physician’s follow-up visits as established patient office visits using 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).

Hope for 2009? CPT 2009 may fix the problem by eliminating consultation codes altogether. If that happens, CMS will average relative value units (RVUs) into office visit and initial inpatient codes, increasing their relative values and ending the consult-versus-transfer-of-care debate once and for all, sources say.