coding & reimbursement
The New Rules for Medicare Consultations
How to document these significant changes.

CMS has made consultation rule changes, which will influence all doctors who order or perform them for Medicare patients. Here is how to integrate the adopted changes.

Q. Were there significant changes to the definition of a consultation? CMS Transmittal 788 updated the Medicare Claims Processing Manual, effective for January 1, 2006. The basic consultation criteria, revised in 1999, remain effective. The updated definition states, "the intent of a consultation service is that a physician or qualified non-physician provider (NPP) or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge." Criteria must still be satisfied and include: a request for the consultation, documentation of the request and need and a written report provided to the referring physician.

Q. Is a consultation still allowed if we initiate diagnostic and treatment services? Yes, as long as there is no transfer of care. The transmittal states,"payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs." Transfer of care is redefined as,
"... when a physician or qualified 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. When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition."

Q. How do we know when a referral is a transfer of care? If the requesting physician does not plan to be involved in any care related to the condition and transfers the care to another physician, then the receiving physician cannot bill for consultation. However, if the patient will be sent back to the requesting physician for follow-up care related to the condition, a consultation applies. Language is a powerful indicator of intent. When the phrasing of the chief complaint in the medical record makes it clear the physician understood the patient's problem and referred the patient for treatment rather than evaluation, then consultation should not be billed.

Q. What are the new documentation requirements? The need to document a request for consult has never been in doubt, but the method of documentation has changed. The transmittal states, "A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP." This conversation most often occurs between staff and the patient.

Q. How should we handle the new documentation requirements? Written documentation of the request for consultation is easier to ascertain with a shared medical record (i.e., group practice, hospital). The request for consult is indicated in the requesting physician's plan and is self-evident to the consulting physician. The nature of the request is less obvious when the medical record is not shared. Although not required, we strongly recommend using a request for consultation form. OM

Suzanne Corcoran is vice president of Corcoran Consulting Group. A sample consultation form may be downloaded from the company Web site at www.corocoranccg.com.

The following is an updated message from our columnist regarding the May Coding column. "There have been recent changes to many Medicare policies on coverage of Avastin, with both the drug and injection now covered. Check your local carrier policies to see if yours has changed."