Part B Insider (Multispecialty) Coding Alert

Make sure you have the written request in your files

Most consults are medically necessary--they just have documentation problems, says one top Centers for Medicare & Medicaid Services (CMS) official.

Good news: You won't get into trouble if you bill a consult and it turns out that the physician who requested the consult didn't have the request documented in his or her files, confirms William Rogers, director of the Physician Regulatory Issues Team at CMS.

The requesting physician is still required to document that request, but it's not the consultant's responsibility to verify that documentation in the requester's files, says Rogers. If the requesting physician fails to document the request for a consult, he or she may not have any reimbursement at stake--but CMS will still hold him or her accountable for bad documentation, says Rogers.
"We're saying to the consultant, 'Do the consultation, that's the most important thing,'" says Rogers. "To delay a consult 24 hours on an ICU patient because you can't find the written request is difficult to support," he adds.

Bad news: That still doesn't let consultants off the hook, however. A couple of problems remain.

Problem #1: CMS also wants the consulting physician to have a written document from the requesting physician requesting the consult. This could prove tricky, says Amanda Kunze, a coder with Wenatchee Eye & Ear Clinic in Wenatchee, WA.

You should either make sure there's a written referral or have a consult request form that you can fax to the requesting physician, advises Quinten Buechner, consultant with ProActive Consulting in Cumberland, WI. You can call the other office and let them know the fax is coming, so they'll be ready to fill it out and fax it back.

Buechner has a check-box  form that allows the requesting physician to specify what he or she is asking for. Options include: advice and treatment, advice and management suggestions, second opinion, evaluation and treatment, opinion and recommendation of care, and recommendation for further care after evaluating the problem. There's also a space to write down the problem.

Problem #2: CMS' new consult guidelines also hint that if the consulting physician goes ahead and treats the problem which led to the consult, that's no longer considered a consult. Instead, it's a transfer of care. The medical director of Part B carrier Noridian came to Wenatchee and told Kunze and other providers that they can't bill a consult if they're also initiating treatment. A consult is only for providing an opinion back to the requesting physician.

"It's going to be really hard to determine what a consult is and what it isn't," says Kunze.

Example: CMS' new manual update on consults includes examples of correct consult billing. (See PBI, Vol. 7, No. 4.) One of these involves an internist who sends a patient with a suspicious lesion to a dermatologist. The dermatologist decides the lesion is probably malignant and removes it, then sends the patient back to the internist with a report. "The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist," CMS says.

This example makes no sense, says Steven Levinson, an otolaryngologist in Fairfield, CT. The internist sent the patient to the dermatologist because she wasn't competent to diagnose the suspected melanoma in the first place. It makes no sense for the dermatologist to send the patient back to the internist for continued monitoring of the melanoma. Instead, the dermatologist should keep tracking the patient's skin.

The consult policy used to distinguish between a transfer of "total care," in which a doctor takes over treating all of a patient's problems, and treatment of just one problem, adds Levinson.

Bottom line: If the consulting physician knows more about the patient's problem than the requesting physician, then it makes sense for the consulting physician to take care of that particular problem. If the consulting physician doesn't know more than the requesting physician, then why is the requesting physician asking for a consult in the first place? Levinson asks.

What you can do: Have a consult request form to fax to requesting physicians, and make sure your doctor turns the patient back over to the requesting doctor after the consult, say experts.