Medicare Compliance & Reimbursement

If you've ever battled Medicare over consult payments, you know how difficult collecting that reimbursement can be. But when you're fighting your carrier to collect for two consults performed in the same practice on the same date, you're really facing an uphill battle. Here's the story from one tenacious office manager who triumphed over Medicare.

Many practices report that Medicare carriers hold fast to their belief that "physicians in the same practice who are in the same specialty must bill and be paid as though they were a single physician" (according to Section 30.6.5 of the Internet Only Manual [IOM]), and have therefore faced denials for intra-office consultations (those in which one physician asks a group member of the same specialty to provide a consultation for his patient).

Exceptions do happen: If your physician practices in a multispecialty clinic, however, you can code the requested service as a consultation. The above-referenced IOM section states, "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group." Therefore, if a primary-care physician requests a consultation from a group member in a different specialty such as a neurologist, the neurologist should bill his service as a consultation rather than an established patient office visit (99211-99215) or a new patient visit (99201-99205).

Problems arise, however, when the subspecialist isn't listed as such with Medicare. For instance, cardiology groups with in-house electrophysiologists (EPs) face problems because Medicare does not recognize EPs as a subspecialty, instead usually credentialing them as cardiologists. This lack of specificity on registration forms works against EP physicians because, based on the above guidelines, these physicians are in the same group, in the same specialty, and may not be able to secure reimbursement for services that they report as consultative if a cardiologist within the same practice requests the consult.

Some payers, such as Health-Now (a Part B payer in upstate New York) recognize EPs' distinctiveness, but others don't.

Follow this trailblazer's example: One resourceful office manager took matters into her own hands. "What we do is bill both services and appeal the one denied with records and a medical necessity letter," says Sylver A. Vasquez, business office manager with Cardiology Associates of Corpus Christi in Texas. "We are successful in getting the denial overturned, stressing the fact that EP is a specialized field in arrhythmia disorders. They want medical records and a copy of the EP physician's EP board certification."

Vasquez reports a 50-percent success rate using her method, but she moves forward with her appeal for the remaining half of these denied claims. "We continue to appeal and have found success because of our persistence," she says. "We don't give up. I have only had to go to the QIC [qualified independent contractor] level twice, and that's only because I forgot to appeal with one of the items essential to the process."

Those items, Vasquez says, are the most important tools that she has in her appeals arsenal, as follows:

1. Consult report from the referring cardiologist to the EP

2. Consult report from the EP

3. Copy of board certification for the EP subspecialty

4. Letter of necessity from the cardiologist advising that the patient's rhythm problem requires the EP physician's expertise.

As always, your consultations must meet the Medicare requirements of request for consult, rendering of the exam, and report back to the requesting physician, says Heather Corcoran with CGH Billing in Louisville, KY.

Practices in this situation continue to hope for changes that would allow them to collect using easier methods.

"I truly believe that CMS needs to create a subspecialty classification for electrophysiology so that the need for continued appeal of a justifiable claim will stop," Vasquez says.