Optometry Coding & Billing Alert

You need not verify documentation, but it should be there

Optometrists who perform consults have been tearing out their hair over the confusing consult documentation rules -- and they just got even more complicated.
 
The Centers for Medicare & Medicaid Services tried to let providers off the hook for the confusing documentation requirements, but CMS- latest clarification just raises more questions, providers say.
 
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, it's not up to Doctor B to make sure Doctor A's files include that request in writing.
 
But CMS officials say that Doctor A still has to document the request for a consult, as CMS stated in last December's Transmittal 788. The only change is that Doctor B doesn't have to verify that Doctor A has done so.
 
It's not clear 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 for consults without that documentation?
 
-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.
 
Chances for clarification: But CMS officials say they-re not planning on clarifying the consult issue any further -- unless providers or carriers indicate that they-re still having problems with the issue. 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.
 
In optometry, patient-requested consultations for second opinions are more common than consultations requested by other physicians. According to new E/M guidelines, you would report an appropriate-level office visit code (99201-99215, Office or other outpatient visit -) for a patient-requested consultation. (For more information on coding for second opinions, see the -CPT 2006 Update- in the December 2005 Optometry Coding & Billing Alert.)
 
Speak up: If you want CMS to put this clarification in a more official form -- let alone dispose of this cumbersome requirement entirely -- make your voice heard, experts say. You can learn about participating in the next CMS physician open-door forum at http://cms.hhs.gov/opendoor/.