Ophthalmology and Optometry Coding Alert

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 prepare a written report for the referring physician.

Then, the definition goes on to discuss consultation followed by treatment. The transmittal directs carriers to pay for a consultation regardless of treatment initiation unless a transfer of care occurs, providing that the above three criteria are met. 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. The receiving physician would report a new or established patient visit (99201-99215) depending on the situation. So when a transfer of care occurs, a consultation cannot be billed.

Inter-group Referrals and
Shared Medical Records

The transmittal also clarifies that the receiving physician can bill for a consultation if the referral came from a physician in the same practice. Therefore, a general ophthalmologist can refer a patient to a retinologist (or any other subspecialist for a subspecialty problem) in the same practice, and the retinologist can bill a consultation. The wording in the transmittal is clear:

Carriers are directed to pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met. The documentation of the request for a consultation, as well as the consultants report, does not have to be by letter, according to HCFA; since both doctors are sharing the patients medical record, documentation of the request for a consultation can be done in the record.

According to the transmittal, in a setting in which the medical record is shared by the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physicians progress note, an order in the medical record, or a specific written request for the consultation. In these situations, the report may consist of an appropriate entry in the common medical record, the transmittal states. In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or if the consultants records show a specific reference to the request. If the medical record is not shared, however, the report must be a separate document given to the requesting physician.

Even though the consultant does not have to send a written letter to the referring doctor in an inter-office situation, it is a good idea for the referring physician to review and initial the consultants findings in the chart, says Rose. That will cover the requirement that the referring physician has received and reviewed the report if you become involved in an audit, she explains.

Be careful about inter-group referrals when it comes to coding levels, says Rose, especially with stacked referrals. For example, an optometrist sends a patient to an ophthalmologist for a cataract. The ophthalmologist does the workup but sees an additional problem and sends the patient to a retina doctor. This all occurs in the same practice. Both the ophthalmologist and the retina doctor can charge consultations. But we think the retina doctor should keep the consultation code low if its all inter-office, because the cataract doctor already did all of the work-up, she says. There will seldom be a Level 3 or higher consultation for an inter-office referral.

Tip: Inter-office consultations have been billable since 1992, notes Rose. But again, some ophthalmologists have not been billing for them because of confusion about Medicare rules and rigid interpretations by local Medicare carriers.

The consultation clarification is great news for subspecialists (e.g., retina, glaucoma and oculoplastic physicians), and ophthalmologists who regularly receive cataract referrals from optometrists. Consultation codes (99241-99245 for outpatient consultations) pay more than office-visit codes (99201-99205, 99211-99215) and at Level 3 and higher pay more than the comprehensive eye examination codes (92004, 92014). The financial incentive for some carriers to restrict consultations is clear. And now there are two real-world problems facing ophthalmologists, regarding referrals. The first is: When will the carriers announce and incorporate this revision into their rules? They have to fall in line with this, says Rose. They have to update their policies as of August 1999 to pay for these consultations. But when will they do it? Sometimes, it takes time for HCFA policy to filter through the carriers to the providers. But you should start coding for the consultations now, regardless of what your carriers says, Rose explains.

If youre going to do a consult, you should get paid for it, says Rose. If the carrier mishandles the claim, you should send a copy of the transmittal to them when they request a review of the claim determination.

No Backbilling

Should you do any backbilling if you have already miscoded consultations as office visits since August? No, backbilling is not recommended in this instance. It could cause more problems than its worth. First, there is nothing in the transmittal about a retroactive effective dateor any date at all. Usually, if backbilling is allowed, it is mentioned in the transmittal.

Second, this could simply red-flag you for an audit, consultants say. Also, remember that the letter from the consulting physician to the referring physician is extremely important. It is the backbone of the consultation. Are you sure you sent letters like that if you were only billing an office visit? Many physicians didnt do the letter; they said, Why bother? because they werent billing a consultation anyway. If, when the carrier publishes this new policy in their bulletin, there is a retroactive date indicated for billing, then you could check records to make sure of the written reports and file for the consultations rendered on or after that date.