New Medicare Policy Could Impact Consultation Billing

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Medical Economics - March 2006  

Specialists who routinely bill initial visits with patients referred by other physicians as consultations likely will need to alter their billing practices under a new Centers for Medicare & Medicaid Services (CMS) policy intended to clarify Medicare rules over when to bill for a consultation versus an office or hospital visit under a referral.

The new Medicare Claims Processing Manual says a consultation is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) seeking an opinion or advice regarding evaluation and/or management of a specific problem. Physicians should not bill for a consultation, which normally pays a higher fee, when a transfer of care occurs. The new policy says a transfer occurs when a physician or NPP asks another physician or NPP to assume responsibility for managing the patients' care for the condition and does not expect to continue treating or caring for the patient.

Consultation coding has been an ongoing problem for both Medicare and physicians. In 2005, TrailBlazer Health Enterprises, the Texas Medicare carrier, asked 767 Texas doctors who bill for consultation services to audit their claims and refund overpayments.

Physicians say consultation coding rules are confusing and often contradictory. TMA has been seeking clarification of those rules for several years.

CMS made the changes in conjunction with the American Medical Association's revision of its 2006 CPT codes. Among those changes was the deletion of the follow-up consultations and confirmatory consultations codes.

CMS also says both the requesting and consulting physicians must document the request and the reason for the consultation in the patient's medical records. The previous policy did not specifically require the referring physician to document the reason for a consult, however E&M documentation guidelines did. Without that documentation, the consulting physician will not be paid or payment likely will be recouped once Medicare becomes aware of the referring physician's failure to document the consultation.

For more information, contact TrailBlazer.   

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