On Dec. 20, 2005, CMS published a transmittal that addressed guidelines for reporting consultation services provided by physicians and qualified non-physician practitioners (NPPs). The criteria for a consult have changed. Or have they?
The transmittal, along with its examples, has caused significant confusion, even for me. To be sure I had the best information available, I sought clarification of the changes from both the national CMS office and CMS’s Denver regional office.
First I will discuss the major changes as published in the transmittal and give a strict interpretation of the rules. Then I will discuss the interpretations as I understand them and provide suggestions on when to charge a consult and when not to charge a consult.
The major changes are as follows:
- The request for a consultation must be documented in the patient’s chart of the requesting physician and in the consulting physician’s chart.
- A consultation request should be made in writing from the requesting physician, or verbal requests should be made by the requesting physician.
- The definition of a transfer of care has changed. The written changes seem to imply that a transfer of care is now considered to occur if the requesting physician intends to have the receiving physician take on complete care for a specified condition.
- A consultation may be requested of another physician or NPP in the same practice as long as the consulting physician has an area of expertise in a specific area that is beyond that of the requesting professional. A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPP within a group practice setting.
- Consultation service may not be shared or split between providers.
Analysis:
What this all means –
As you probably know, there are three parts to any regulation: the regulation, the interpretation of the regulation, and the implementation of the regulation. Unfortunately, Medicare rules and regulations have many interpreters, including the central CMS office, each regional CMS office, and each of the Medicare carrier medical directors.
The following text was copied from the transmittal (Requirement #4215.17):
“Carriers shall instruct physicians and qualified NPPs that a consultation request may be verbal. However, the verbal interaction identifying the request and reason for a consult shall be documented in the patient’s medical record by the requesting physician or qualified NNP, and also by the consultant physician or qualified NPP in the patient’s medical record. A consultation request by the requestor may be written on a physician order form in a shared medical record.”
This interpretation would indicate that the documentation must be in both the requesting physician’s and the consulting physician’s charts. The most rigid and strict interpretation would be that a consultant is required to read the other physician’s medical record, obtain a written request, or have a confirmation that the requesting physician has documented the request in his chart. It would indicate that a CMS audit of a consultation could include analysis of the requesting physician’s record. Although problematic, this could be done, and it leaves the consultant physician at risk of losing a consult charge even if all their “i”s are dotted and “t”s are crossed.
I spoke with Bill Rogers, MD, director of the Physicians Regulatory Issues Team at CMS. I specifically asked him if a consulting physician is required to have confirmation that the requesting physician has the proper documentation in his chart.
“That was not the intent of CMS,” Dr. Rogers told me. “CMS understands that would be a lot of wasted time on the part of the physician and their offices as well as CMS in trying to verify the requesting physician’s documentation or to require a written request for a consult.”
Although his office was not the one that published the transmittal, he indicated that there was a move to change the phrase “and also” to “or” in the transmittal. If that occurs, it will remove any controversy about the need to confirm the documentation in the referring physician’s chart and kill forever the idea that a written request is necessary
Cathleen M. Scally, MS, CNM, of CMS’s Division of Practitioner Services, indicated that the communication could be between the physician’s office staff during the Physician’s Open Door Forum in late January and was not required to be physician-to-physician.
The new rules again make it clear that the consulting physicians can start treatment without jeopardizing the consultation charge. It also confirms the need for transfer of care to be agreed upon by the consulting physician prior to seeing the patient. The new regulations also make it clear that transfer of care could be for the care of a specific problem.
Actions to take –
In light of these changes, here are a few things you should be doing:
- Continue to include the requesting physician and the reason for the consult in your documentation.
- If you’re confident that the patient was referred by a qualified provider, then you should not spend time confirming that the referring physicians have done their job in documenting the request. However, if you think the patient was referred by a qualified provider, but there is reasonable doubt, have your office confirm the request with the referring physician’s office.
- Send written documentation of your findings to the referring physician.
- Do not charge a consult if there is an agreement by the consulting physician to take over complete care of the patient for that problem prior to the patient’s visit or if it is an obvious transfer of care in the eyes of the consultant. If the patient is referred for an unknown problem, if the referring provider will continue to be involved in the treatment, or if there is a need for determining the appropriate treatment, then a consultation should be charged, even if the consultant takes over treatment.
However, many referrals are shades of gray. Is it a consult or not? CMS understands that there is a huge gray area that is open to interpretation. Gray is not all bad. You make the choice.
The rules for same practice consults were made more precise, but no major change.
The last point is a new clarification and is quite clear: No shared work on consults!
In summary, the rules for consultations have become a little more precise, but have not changed significantly. Watch your Medicare bulletins carefully to see what you are required to do in your state. Continue to obey the rules, code the obvious black-and-white issues correctly, and interpret the gray areas to the best of your abilities, realizing that you will not be shot at dawn or lose the family farm if you’re wrong.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
