Ophthalmology and Optometry Coding Alert

You aren't responsible for the requesting physician's files, CMS says

Recent Medicare rules have had ophthalmologists worried that they'd be responsible for other physicians' consult request documentation. CMS now says that this isn't the case, but it hasn't offered new guidance on how it will handle "incomplete" consult requests.

New rule: A statement by the Physician Regulatory Issues Team at CMS says that the consulting physician doesn't have to verify that the requesting physician documented the request for a consult.

In other words: When Doctor A requests a consult from Doctor B, Doctor B isn't responsible to make sure Doctor A's files include that request in writing.

But CMS officials still insist that Doctor A has to document the request for a consult, as CMS stated in last December's Transmittal 788. (See "Prepare for a New Crackdown on Consult Coding" in the May 2006 Ophthalmology Coding Alert.) The only change is that Doctor B doesn't have to verify that Doctor A has done so. 

So, what will happen if the carrier audits Doctor B and doesn't find any request documented in Doctor A's files? Will Doctor B still get paid? At this point, CMS hasn't been able to answer that question.

"It is a real paper chase for the consultant to have to look at the referring physician's notes to see if they are in compliance," says Roberta Buell, vice president of provider services and reimbursement with P4 in Sausalito, Calif. CMS should delete the requirement for Doctor A to document the request for a consult altogether, she adds.

The issue isn't resolved: CMS officials say they're not planning on clarifying the request-for-consult issue any further--unless providers or carriers indicate that they're still having problems. CMS doesn't even plan to put out a transmittal or manual update spelling out this latest clarification partly letting consulting physicians off the hook.

Best bet: The best advice, for now, is to try to do your best to ensure that your office documents all consult services carefully and, if possible, suggest that the physicians requesting those services do the same by using a "consult request sheet" as provided in the May 2006 Ophthalmology Coding Alert.

Note: To read the statement from the Physician Regulatory Issues Team, visit www.cms.hhs.gov/PRIT/PRITIA/list.asp and click on "Written Consultation Orders." You can download MedicareTransmittal 778 at www.cms.hhs.gov/transmittla/downloads/R788CP.pdf.

Stay tuned: Several associations have requested further clarification from PRIT. On June 15, the Indiana State Medical Association and others who feel confused by the definition of Transfer of Care found in Transmittal 788 asked PRIT to provide additional clarification.

Then, on July 10, the Infectious Disease Society of America, the American College of Physicians, the American Medical Association, and several other specialty societies also contacted PRIT about clarifying the definition of a consult in transmittal 788.

PRIT replied that they are working to address the issue, and state on their Web site: "This issue was discussed at the Aug. 28, 2006, meeting of the Practicing Physician's Advisory Council." 

No additional information was available at press time to provide any insight as to the outcome of the discussions, but Ophthalmology Coding Alert will keep you updated.