Ob-Gyn Coding Alert

Documentationby both the primary and specialist physicianis the key to have specialty services paid as a consultation because a new Medicare revision does little to define complete care.

The less-than-comprehensive update requires careful documentation by ob/gyns performing consultations for other physicians. But the recent clarification did partially clarify when the services of specialists may be considered consultative. Transmittal No. 1644 resolved lingering issues from previous revisions about when a transfer of care occurs.

HCFA is responding to the confusion in the coding and clinical community, but only to a point. Sometimes they make these things ambiguous on purpose. They dont want to make it so specific that they back themselves into a corner. This will leave people arguing about the definition of complete care, says Deb Lief, CPC, manager of coding compliance at ProMedCo in Fort Worth, TX. Lief is also president of the North Texas Chapter of the American Academy of Professional Coders.

The transmittal, a revision of section 15506 of the Medicare Carriers Manual, states that a consult may be billed regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. It was apparently intended to clarify an update issued in July 1998 that made clear that a consultant could initiate diagnostic and therapeutic services on the same day. However, it also added confusion by stating that the visit could not be billed as a consult if partial or total care of the patient had been transferred.

The two transmittals, which involve Sections A and B of 15506, should make it more evident that even when specialists initiate treatment, they are still performing a consultation. In fact, the two more closely align Medicares definition of a consultation with that of CPT 1999, which states that a physician consultant may initiate diagnostic and/or therapeutic services.

However, they seem to conflict with Section G of 15506, which has not been updated. A guideline for consults during postoperative care, Section G says that if the surgeon asks a physician who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patients condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physicians opinion or advice for the surgeons use in treating the patient. The physicians services would constitute concurrent care and should be billed using the appropriate-level visit codes.

These discrepancies leave practices open to denials, depending on carriers reading of the updates and Section G, and their definition of complete care.

Requests for consultation often start over the telephone. An internal-medicine practice, for instance, may call a gynecology practice and make an appointment for a patient with postmenopausal bleeding. The internist may also speak about the patient directly with the gynecologist.

Whether the call is between office personnel or physicians, that initial conversation should clarify the primary-care physicians expectation, according to Leslie Huck, billing specialist for Gateway Womens Clinic, a five-physician gynecology practice in Portland, OR. Our receptionists know to ask whether its a consultation or transfer, and our physicians are extremely good about asking the primary-care doctor what they want and asking what service is needed, she says.

Such communication enables the consulting office to clearly understand what the primary-care physician (PCP) wants, but it should be followed up by a brief letter documenting the request.

Be cautious of saying, Im referring or Im transferring this patient to you, Lief advises. The specialist may understand that the ob/gyn means for him to diagnose and treat only a specific aspect of your patients condition, but the Medicare carrier may see it as a clear indication that you were asking the specialist to assume complete care responsibilities.

Once your ob/gyn sees the patient, he should send a written communication explaining his diagnosis and treatment to the requesting physician.

This request-render-report cycle is described in Transmittal 1644s guidelines for consultation:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings, and the report is provided to the referring physician.

The clear documentation will demonstrate the appropriate use of consultative codes and help refute any carrier denials. Although its too soon to gauge how carriers on the whole will interpret Transmittal 1644, there are already reports of some denials.