Medicare Compliance & Reimbursement

A consultation is a single physician's opinion, not a consensus.

Consults are hard work, and physicians may be tempted to share the load. But consulting physicians should do all of the work themselves, according to the Centers for Medicare and Medicaid Services.

CMS is revising the Medicare Carriers Manual to clarify that physicians doing inpatient consults can't bill for a "shared visit," say CMS officials. Physicians should report shared visits to bill for E/M services jointly performed by a physician and a non-physician practitioner under the physician's provider number.

There's currently nothing in writing that says a doctor can't bill a consult as a shared visit. But the CMS definition of a shared visit says the service must follow all the rules of an "incident-to" service - including that there should be an established patient with an established problem. Usually these aren't the circumstances with a consult. The Same Goes For Critical Care Physicians also shouldn't provide critical care as a shared visit, the official adds.

Why do it? Billing for shared consults has never really been acceptable, but a lot of specialists probably do it because a consult can take 45 minutes, notes Lois Curtis with Gastroenterology Associates in Evansville, IN. The NPP can go in, obtain background information and "narrow it down" for the doctor, who then "goes in and gets the end portion of it."

"Ideally it would be great if they could share that visit, but according to the definition of the consult it doesn't work that way," says Curtis.

When a doctor asks for a consultation, she's requesting one physician's opinion, notes consultant Jim Collins with Compliant MD in Matthews, NC. "Therefore, two providers can't do it," he says.

Non-physician practitioners already don't perform any part of consults at CNY Cardiology in Utica, NY, according to coding specialist Sarah Tupper. The NPPs "just do the admit and discharge and the hospital visit, and the doctors do the consults themselves." CNY's board set a policy some time ago that physicians need to perform consults personally to render their own opinions.