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Medicare changes its rules on consult requirements

CPT code revisions and new policies mean consultation documenting and reporting changes for internists

From the March ACP Observer, copyright 2006 by the American College of Physicians.

By Carol McKenzie and Brett Baker

Q: I understand that changes to the Current Procedural Terminology (CPT) codes for 2006 deleted the follow-up inpatient and confirmatory consultation codes. In light of those changes, has Medicare changed its rules pertaining to consultations?

A: Medicare made some rule changes to accommodate the deleted consultation codes—and used that opportunity to make additional changes unrelated to those deletions.

Q: What rule changes has Medicare put in place for requesting physician and consultation documentation?

A: First, let's briefly go over how Medicare defines a consultation and what consulting physicians need to do to get reimbursed.

According to Medicare's definitions, a consultation occurs when a physician requests the opinion or advice of another physician on the evaluation and/or management of a specific patient. During a consultative visit, a physician:

  • must offer an opinion or advice to the requesting physician;
  • must make a decision for treatment option(s); and
  • may perform and/or order distinctive diagnostic or therapeutic procedures.

To be reimbursed, the consultant must document that advice or opinion, as well as any services performed or ordered. The consultant must also send a written report detailing that opinion and any diagnostic or therapeutic services performed to the requesting physician.

Medicare hasn't changed any of those definitions or reimbursement requirements—but it has elaborated on its documentation rules. A physician request for another physician's opinion can be in writing or verbal. Requesting physicians must now document their request in the patient's medical record. That documented request also needs to refer to the patient's plan of care.

Consulting physicians must also document in the patient record both the request and the reason for it, by either using the requesting physician's written request or documenting a verbal discussion. If the two physicians can access a shared medical record—which is often the case in large medical groups—consultants may include their written report in the record without sending a separate letter to the requesting physician.

Q: If the attending physician requests a second consultation—from either the same physician or a different one—related to a new condition or a change in medical status, how should the attending report that second encounter?

A: The answer depends on the setting. In last month's column, we covered how to report a second consultation on the same patient in the hospital.

In an office or other outpatient setting, consultants must report the following in a second consultation:

  • the appropriate office or other outpatient consultation code for the initial consultation in the office/outpatient setting.
  • the appropriate office or other outpatient consultation code for services following the initial office consultation when the same or a different physician requests an additional opinion on the same or a different condition.
  • the appropriate established patient office visit code for services following the initial office consultation service if he or she has assumed responsibility for all or a portion of the patient's care.

Q: How do these CPT code changes affect coding and billing for a second opinion?

A: Prior to the CPT 2006 changes, physicians rendering a second opinion would report their involvement using now-defunct confirmatory consultation codes. As mentioned in last month's column, patient-initiated second opinions provided in the outpatient setting should be reported using the appropriate office or other outpatient code. The physician rendering a second opinion requested by another physician can continue to report that service using the appropriate office or other outpatient consultation code.

In a facility setting, the physician providing the second opinion should report the appropriate initial inpatient consultation code. That is because the second opinion is being arranged through or requested by the attending physician.

Q: What are reporting rules if the consultant works in the same practice as the requesting doctor?

A: In this scenario, Medicare will pay for a consult when the consulting physician has expertise in a specific medical area beyond the requesting physician's knowledge. In most cases, the same group consultant will practice a different specialty than the requesting physician.

Q: Can I be reimbursed if I consult in a patient's postoperative care?

A: Report the appropriate consultation code for the setting in which the service takes place—office, hospital, nursing facility—if your opinion is wanted regarding a particular aspect of the patient's postoperative care. However, you need to report the appropriate subsequent care code for the setting in which the service takes place if you performed a preoperative consultation to determine the patient's fitness for surgery and/or if the surgeon transfers responsibility for all or a portion of the patient's postoperative care to you.

Carol McKenzie is Administrative Coordinator for Regulatory and Insurer Affairs in ACP's Washington office. Brett Baker is Director for Regulatory and Insurer Affairs, also in ACP's Washington office.

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Medicare Part D resources

  • ACP has created a Medicare Part D Web site with practical information for physicians, staff and patients.

  • The College has also created a Web site for members to e-mail specific Part D-benefit problems and get help from ACP staff. Post questions online or call the ACP Part D helpline at 800-338-2746, ext. 4535.

  • The Centers for Medicare and Medicaid Services (CMS) has set up an e-mail address for providers to use to report problems with a particular drug plan. When sending an e-mail, include as much information as you can—except the patient's name—on the specific problem.

  • A new Web site created by the CMS lets physicians find out what specific drugs are covered by individual Medicare Part D health plans. The CMS' new formulary finder allows physicians to research a drug's availability by state. The site also provides a list of all Part D plans in each state, with direct links to a plan's home page for a complete formulary. PIER, the College's online educational resource, also has a link to the CMS formulary finder.

  • The CMS has also created an online 'exceptions and appeals' contact list for providers for each prescription Medicare Part D plan. Patients encountering Part D problems are encouraged to either call their drug plan directly or, if unsuccessful, use the 800-MEDICARE hotline.

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