Medicare Transmittal Clarifies Consultation
Published on Mon Nov 01, 1999
A new revision in the Medicare Carriers Manual (Transmittal 1644) means that ophthalmologists can charge a consultation (99241-99275) and also treat the patient, providing the patients entire care has not been transferred to the ophthalmologist.
For example, an ophthalmologist refers a patient to a retinologist, who examines that patient and determines surgery is necessary. The retinologist performs the surgery and sends the patient back to the ophthalmologist for general care. How should the retinologist code the first visit: office visit or consultation? The answer used to be: It depends on how your carrier interprets the Medicare definition of a consultation. The answer now is: Its a consultation. Recently, the Health Care Financing Administration (HCFA) issued Transmittal 1644, a revision to Section 15506 of the MCM.
Before the transmittal was issued, many physicians and coders believed you could not treat a patient and charge a consultation for the first visit. Now you can treat and it will still be a consultation, says Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY, and an ophthalmology compliance and reimbursement consultant. Because of the way this section used to be written, many carriers interpreted it quite rigidly and didnt reimburse when care was initiated after a consultation, she notes. HCFA never intended for local Medicare carriers to interpret it that way. Of course, carriers interpret these regulations to their own advantage, and if there is any vagueness in wordingas there often isthen different carriers will have different rules.
In fact, some carriers never had the rigid interpretation of a consultation, and ophthalmologists who were in these areas have been able to bill consultations all along, explains Ann Rose, president of Rose and Associates, an ophthalmology billing and compliance consultant based in Duncanville, TX. All of our clients have been billing consultations for years, she says. And I dont know of anyone who was ever denied a consultation who treated the patient as well. Nevertheless, many carriers did have the strict definition of a consultationthat it be used only when a patient was sent to them only for an opinion and advice, not for treatment. True, if all of the patients care is transferred to you, you cannot bill a consultation. However, doing one surgery on a patient is not transfer of all the general or specialty care.
Consultation Followed by Treatment
Here is how the most recent Medicare transmittal defines the criteria for a consultation:
- The consultation must be provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician;
- The need for consultation must be documented; and
- After the consultation, the consultant must [...]
