Optometry Coding & Billing Alert

Get to know the 5 consultation keys -- we-ll tell you what they are

Rumors had circulated that CPT 2008 would offer you updated, clarified guidance on the difference between a consult and a transfer of care, but you won't find that guidance in the CPT manual. Here's what you need to know.

When you-re trying to code consultation services, one of the first questions you need to ask before reporting 99241-99245 (Office consultation for a new or established patient -) is whether the requesting physician transferred the patient's care to you or is asking you for an opinion/recommendation.

"The verbiage of the consultation guidelines illustrates that the provider can actually initiate treatment and order tests," but then you-re left to ponder what would truly be classified as a transfer of care, says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh and past member of the AAPC national advisory board.

Bad news: Unfortunately, the experts still can't agree how a consult differs from a transfer of care. The AMA's CPT Editorial Panel failed to reach a consensus on how to clarify the consult definition at its meeting, according to CMS- Physician Regulatory Issues Team (PRIT). That's why there was no clarification in the CPT 2008 update.

CMS was hoping the CPT update would settle some of the confusion that the agency created with Transmittal 788, according to William Rogers, the PRIT's chairman. "A transfer of care occurs when a physician or qualified NPP [nonphysician practitioner] requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition," CMS wrote.

The problem: That sentence worried many providers, who thought that CMS was barring them from coding a consult when a physician requests an opinion on a patient for a specific problem, and the specialist, such as an optometrist, then treats it. For instance, a family practitioner sends a patient who has a superficial foreign body embedded in his eye to you for possible surgical solutions. Does this typical scenario qualify as a consult or as a transfer of care?

CMS could still clarify the consult issue with another transmittal.

Good news: You won't likely receive a denial based on this issue, but it could present a problem in an audit, Rogers added. So far, he hasn't heard of either the Recovery Audit Contractors (RACs) or the carriers themselves auditing providers- consults in such detail.

Medicare regulations state that carriers will pay for a consultation that meets five criteria: a request from a referring physician, the reason for the request, a patient review, a written report sent to the requesting physician, and the return of the patient to the requesting physician.

What to do: If a physician sends a patient to you for a consult, and you decide to treat the problem, send the requesting physician a letter first. The letter should explain the patient's problem, the physical findings, the diagnosis, your opinion and recommendations, and state that considering the findings and conclusions the two providers have agreed that you will provide care for this problem.

You should code your initial service as a consultation using 99241-99245. Then code your follow-up visits as established visits using 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient -).

Hope for 2009? CPT 2009 may fix the problem by eliminating consultation codes altogether. If that happens, CMS will average relative value units into office visit and initial inpatient codes, increasing their RVUs and ending the debate over consult versus transfer of care once and for all, sources say.