Medicare Compliance & Reimbursement

Question: Our physicians offered consultation services to a patient who was in treatment with another physician. How can we bill the consultation? Is it important that the consulting physician takes over the care of the patient?

Illinois Subscriber

Answer: You can report 99241-99245 (Office consultation for a new or established patient ...) if a physician takes over treatment of the condition; but, this does not assume a transfer of care. It is possible that a consultant may treat a patient and ultimately take over care for the condition the consultant has been asked to evaluate. You can think of the patient as being “borrowed.” The patient, however, may need to return to the referring physician during the course of management. After the consultant sees the patient, the patient can go back to the originating provider to discuss the options, see another consultant, or perhaps, decide to have the consultant take care of the issue. The intent of the original visit is still that of a consultation.

Reminder: To bill a consultation code, you need to ensure your provider’s documentation meets the following criteria:

• Reason for consult
• Request for your doctor’s opinion
• Rendering the service in order to develop an opinion (the consult visit)
• Write a letter (or auto generate a letter) to the requesting doctor with the opinion
• Return the patient once the course of treatment is complete.

Check with your payer: If you are billing Medicare or another payer that no longer recognizes the consultation codes, then you cannot use these codes for the consultation. The intent of the visit doesn’t change, however and would be reported with a new or established office/outpatient E/M visit code depending on the patient’s status with the group practice of the consulting physician.