Part B Insider (Multispecialty) Coding Alert

If you performed a consult in 2006, the auditor will use 2006 guidelines -- not today's rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for these services. However, if an auditor comes calling and wants to review your consult notes, he will be judging you based on the Medicare rules as of the date of service.

Some practices assume that any audits taking place in 2010 or thereafter that involve consult notes will be based on CPT consult rules, and not Medicare's, since Medicare does not recognize consult payment as of  2010. Because Medicare's consult regulations were generally more strict than CPT's, practices consider this a small victory. But this is inaccurate, experts say.

"If the auditor is reviewing services you performed in 2009, CMS rules from 2009 will apply," confirms Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC with CRN Healthcare Solutions in Tinton Falls, NJ. "In 2006, Medicare changed the rules -- so if they audited 2005 consult services, it would be a different standard than 2009 services as well," she says.

The Medicare auditor may not just want to read your physician's notes, but may even request notes from other practitioners if it's necessary to back up your claims.

"In evaluating consults, I have even experienced one audit where they also requested the referring physician's documentation to substantiate the reason for the consult," says Devona Slater, CHC, CMCP,  president and compliance auditor with Auditing for Compliance and Education Inc. in Leawood, Kan.

"Medicare's definition of a consult and the CPT definition have always been different and a reason for confusion," Slater says.

Slater says she has seen auditors who find that practices don't have adequate consult documentation "downcode the consults to new or established patient visits and request a refund for the difference."