Orthopedic Coding Alert

Question: In a recent discussion on the Orthopedic Coding Discussion list serve [accessed by going to www.medville.com/list/ then clicking on ortho], I believe the example regarding the wrist fracture not being a consultation is incorrect. The transfer of care relates to the total transfer of care, not for a specific problem. Review the Medicare carrier rule, 15506, on the HCFA Web site. The example is a consultation and fits all the criteria request, review and report. The patient will still return to his family doctor for routine care, not the orthopedic surgeon. This is no different from the patient sent to the general surgeon for a breast lump. The surgeon examines the patient, sends a report, biopsies the lump and sees her for follow up as needed. For routine medical care she still returns to the family physician, not the general surgeon. The first surgeon visit is a consultation.

Richard Cunningham, MD
Carolina Orthopedics, Gastonia, N.C.

Answer: The following is the exact excerpt from the current Medicare Carriers Manual, updated in August 1999 to reflect the new wording of the instructions for consultations. Please note in paragraph A 1 the phrase regarding evaluation and/or management of a specific problem, and also in section F, listed below, is a reference to transfer of care, described as management of a portion or all of the patients condition(s) ... Although a phrase in section B refers to complete transfer of care, these excerpts give clear definition that transfer of care is referred to as care for a specific problem. Although there have been other less conservative interpretations of this wording in the past few months, our recommendations are based on the consensus of many consultants across the country after discussions of this issue with their local Medicare carriers. It is highly recommended that if you view consultations differently from the recommendations made in our issue that you contact your local Medicare carrier for clarification of their interpretation in writing.

15506. CONSULTATIONS (Codes 99241-99275)
A. Consultation versus Visit. Pay for a consultation when all of the criteria for the use of a consultation code are met:

(1) Specifically, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

F. Post-Operative Care By Physician Who Did Pre-Operative Clearance Consultation. Advise physicians that if, subsequent to the completion of a pre-operative consultation in the office or hospital, the consultant assumes responsibility for the management of a portion or all of the patients condition(s) during the post-operative period, the consultation codes should not be used. In the hospital setting, the physician who has performed a pre-operative consultation and assumes responsibility for the management of a portion or all of the patients condition(s) during the postoperative period should use the appropriate subsequent hospital care codes (not follow-up consultation codes) to bill for the concurrent care he or she is providing. In the office setting, the appropriate established patient visit code should be used during the post-operative period.