Otolaryngology Coding Alert

Question: Has CMS sorted out the difference between a consult and a transfer of care? Will CPT 2008 clarify the issue?

North Carolina Subscriber

Answer: Unfortunately, the experts still can't agree how a consult differs from a transfer of care. The CPT Editorial Panel failed to reach a consensus on how to clarify the consult definition at its February meeting, according to the Physician Regulatory Issues Team (PRIT) at CMS. That means there won't be any 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 [nonphysician practitioner] NPP 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.

That sentence worried many otolaryngologists, 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 then treats it. For instance, a pediatrician sends a child who has chronic otitis media to an ENT for possible tubes. Does this typical ENT scenario qualify as a consult or as a transfer of care?

CMS could still clarify the consult issue with another transmittal, but -things have really slowed to a crawl- with preparation for next year's physician fee schedule and other rules, Rogers says. He and another CMS official spoke to the American Academy of Nurse Practitioners in early April and -got beat up about the consult issue.- So they-re aware that -people would like to see a clarification sooner rather than later.-

Rest easy? You-re not likely to receive a denial based on this issue, but it could present a problem in an audit, Rogers says. So far, he hasn't heard of either the Recovery Audit Contractors (RACs) or the carriers auditing providers- consults.

What to do: If a physician sends a patient to your otolaryngologist for a consult and your surgeon decides to treat the problem, send the requesting physician a letter first. The letter should explain the patient's problem and state that the two physicians have agreed that the specialist will take care of it.