Otolaryngology Coding Alert

Documentation is still the key to getting paid for consultations, because while a recent Medicare clarification says consult physicians can initiate treatment there is still a question about complete care.

A previous series of clarifications by Medicare regarding what is and is not a consultation has done anything but clarify the issue for many otolaryngologists. This new Medicare revision, however, may be a step in the right direction. According to Transmittal No. 1644 (Medicare Carriers Manual), which recently went into effect, a consult may be billed regardless of treatment initiation unless a transfer of care occurs. 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.

Therapeutic/Diagnosis Treatment

According to some coding experts, the new revision means the physician performing the consultation now can initiate therapeutic as well as diagnostic treatment on the same day, as long as complete care of the patient has not been transferred, and the otolaryngologist is not simply following the instructions of the requesting physician.

Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Phoenix, AZ, believes the new revision will make it much easier to bill for consults. Before, our understanding of the consult was that if the doctor treated the patient it wasnt considered a consult, it was an office visit. All the otolaryngologist and other specialists could do was offer advice and their opinion to the requesting physician. To initiate treatment, he would have to stop and call the attending physician.

Zmuda adds that when a patient comes in to see the otolaryngologist and needs help, the last thing the physician wants to say is, Look, I know whats wrong and how to treat you, but I need to talk it over with your PCP first. So they would treat the patient before talking with the PCP, and consequently, couldnt bill for a consult. Now, she says, they can initiate treatment.

Under the new guidelines, if the pediatrician, as the attending primary-care physician, sends a 10-year-old boy with a chronic ear infection to the otolaryngologist after treating him repeatedly with antibiotics, and the ENT evaluates the child by doing a culture of the ear to determine what kind of bacteria is causing the infection and gives the child IV antibiotic therapy, the otolaryngologist may still claim for a consult.

The new guidelines are telling us that if a doctor sends the patient to a specialist and asks for opinion and his advice, and the documentation states that, he can go ahead and initiate treatment of the patient, Zmuda says.

Confusion Over Complete Care

Other coding experts say that until the definition of complete care is resolved, the issue will continue to fester. A previous revision issued in June 1998 also stated that a consultant could initiate diagnostic or therapeutic services, but muddied the waters by stating that the visit could not be billed as a consult if partial or total care of the patient had been transferred. That meant that some carriersMedicare and commercialwould not pay for a consult if any aspect of the patients care was being managed by the specialist.

By clarifying when a transfer of care occurs, the new revision also brings Medicare closer to the definition of a consultation in CPT 1999, which clearly states that a physician consultant may initiate diagnostic and/or therapeutic services.

Under HCFAs revised guidelines, the basic requirements of a consult are:

1. 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).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.

Note: The consultation request should be retained in the patients files in case Medicare asks to see it.

Initiating Treatment

According to Teresa M. Thompson, CPC, an ENT coding and reimbursement specialist in Carlsborg, WA, Medicare has done a better job of explaining the difference between a consult and a referral and gives the otolaryngologist more opportunity to initiate treatment, but there are still some questions that remain.

The revision says the requesting physician must include the specific reason for the request, but doesnt define the meaning of specific, Thompson explains.

Like other coding experts, Thompson also notes that there is still room for interpretation on the meaning of complete transfer of care. And she also points out that, even with the new revision, the patient is expected to follow up with his or her primary-care physician. That leads to the question of how to define the first visit should the patient return for further evaluation. Under these circumstances, she wonders if the first visit will be classified as a consult, especially if the otolaryngologist knows a second visit will be necessary for further evaluation of the patient.

What is certain, Thompson says, is that even with the new regulations, certain first visits to otolaryngologists will definitely not qualify as consults. For example, if a patient with chronic otitis media (381.3, other and unspecified chronic non-suppurative otitis media) is sent to the ENT physician specifically for tube placement (69433, tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia), that would be considered a complete transfer of care for that particular problem and, therefore, billing a consultation would be inappropriate.

However, she says, if a primary-care physician sends a patient with chronic sinus congestion to the otolaryngologist for evaluation after having given that patient multiple courses of antibiotics, that visit should be billed as a consult, because the ENTs course of action is not pre-determined. He or she may decide to perform sinus surgery, test for allergies, irrigate the sinuses or put the patient on a different course of antibiotics.

Documentation Must Support Service Level

There are a lot more problems with coding for consultations than simply the question of what constitutes a transfer of care or complete care, according to Dari Bonner, CPC, CPC-H, CCS-P, president of Xact Coding and Reimbursement in Port St. Lucie, FL.

The new clarification may define it better for people who in the past may have questioned the meaning of transfer of care, Bonner says. But everyone seems to have gotten away from what really needs to be said about consults, which is that the documentation requirements are rarely there.

At a high level of service (99244, office consultation for new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity; 99245, medical decision-making of high complexity; 99254, initial inpatient consultation, comprehensive history, comprehensive examination and medical decision-making of moderate complexity; and 99255, medical decision-making of high complexity), the documentation must support all three components, she says, which can be difficult.

Note: Use of the word referral should be avoided, as this indicates a transfer of care.

For Bonner, the new clarification is not a big change, but she worries it will convince otolaryngologists to bill consults when they are not appropriate and, therefore, spur more audits.

There is no difference at all in the new language. All along, Medicare guidelines said you could initiate treatments on the first visit and even do follow up. So in my opinion, the language hasnt changed, and it shouldnt be used to justify more consultations in the future, because thats not its intent, she says, noting that when modifiers -25 (significant, separately identifiable evaluation and management service by the same physician on the same day) and -59 (distinct procedural service) were clarified, they were overused, audits ensued, and some carriers began to routinely deny every claim with those modifiers.

If the clarification defines the consult guidelines in plain English, thats great, but if consults are misused, the government will start to nail us next year. Theyll say we misinterpreted their memo, she says.

Cynthia Thompson, CPC, a senior coding specialist with Gates Moore and Company, an Atlanta, GA-based consulting firm, recommends that requesting physicians create a simple consult request form to help clarify the intent of the request. The form would include a request for the patient to see the consultant physician, the patients diagnosis and the time range when the patient should be seen. It also would indicate whether the appointment was

1) a consultation, or
2) a referral for treatment and/or management.

She says that the form protects both the requesting and consulting physicians by documenting in writing what the appointment with the specialist was for.

Moore also suggests that a member of the consulting otolaryngologists staff call the requesting physician to indicate that treatment is going to be started. Even though such a call is not technically necessary before the consultant begins treating the patient, Thompson says documenting the call to let the requesting physician know what is going on is a good idea.