CMS Raises Stakes for Consults, Adds Documentation Onus for Referring M.D.

January 31, 2006

Reprinted from the Jan. 9, 2006, issue of REPORT ON MEDICARE COMPLIANCE, the nation’s leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

New Medicare documentation demands for consultations present a reimbursement and compliance challenge: CMS says that effective Jan. 17, the reason for a patient consultation must be documented in the medical records of both the ordering physician and the consulting specialist. The outcome of the consultation must also appear in both physicians’ medical records, according to Medicare Transmittal 788 (Change Request 4215), issued Dec. 20.

The new guidelines make it clear that both the requesting physician and the consulting physician must document the request and the reason why. This change is very significant for physicians, contends Jean Acevedo, president of Acevedo Consulting in Delray Beach, Fla.On the one hand, she says, Medicare is trying to prevent abuses in billing for consultations, which pay more than regular office visits. On the other hand, specialists’ reimbursement is now hostage to primary care physicians’ willingness to take an extra documentation step when there’s no financial stake for them.

CMS made these changes in response to CPT code revamping for 2006, she says. The American Medical Association (AMA) clarified the documentation necessary for a service to be considered a consultation instead of an office visit. AMA deleted two sets of consultation codes from the CPT codes: follow-up consultations and confirmatory consultations (also known as second-opinion consultations). “That makes some sense because there had always been confusion among docs [regarding] when to appropriately use them,” Acevedo says.

But along with those changes came the unexpected from CMS, she says. Some of the CMS clarifications regarding the definition of consults and documentation requirements for consultations threw physicians for a loop. In particular, CMS revised the carrier’s manual to state that the consultation by the referring physician (i.e., the primary care physician) must be documented by the referring physician in his or her records – something that was never required before.

CMS explains in the transmittal, “A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s [i.e., nonphysician practitioner’s] plan of care in the patient’s medical record.”

Without this documentation, Medicare won’t pay for the consultation. Though Medicare may not know whether that note is in the medical record when the claim is submitted, Medicare auditors later will realize whether the primary care physician put the reason for the consultation in the patient’s medical record. If it’s not there, the carrier will recoup the money, and the consultant will be fresh out of luck — and money — Acevedo says.

Physicians Lack Financial Incentive

“There is no financial incentive for the primary care physician to do this. These doctors have relationships and talk to each other orally,” she says. The referring physician doesn’t typically write his thinking in the chart. It’s an informal network.

According to the transmittal, the 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 NPP and also by the consultant physician or qualified NPP in the patient’s medical record.”

Acevedo says the only reason she can see for Medicare’s decision to crack down on consultations is to ensure there is “validation and verification that when consulting physicians says it is a consult, it really is a consult.” Consultations pay substantially more than office visits, she notes.

For example, in Miami, CPT code 99203, which is a Level 3 new patient office visit, has a Medicare allowable charge of $103.85. In contrast, CPT code 99243, which is a Level 3 consultation, has a Medicare allowable charge of $132.14, Acevedo says. And, she concedes, there are some physicians who claim that every patient they see is a consultation. The new rules “will make it that much harder for physicians to just document in their consultation report that a service is a consultation,” something that until now they have done with virtually no oversight or limits, Acevedo says. “From now on, if the primary care physician doesn’t intend it as a consultation and document it that way, Medicare won’t pay it that way.”

How can consulting specialists increase the likelihood that referring physicians will put the necessary documentation in their medical records so that consulting physicians can get their proper reimbursement?

Acevedo has one suggestion: Specialists can fax a preprinted form to referring physicians that asks them to check off whether the referral is for the patient to have a consultation or for management (a regular office visit). The referring physicians are asked to both stick the original in the patient’s chart and fax the form back. That keeps the work very minimal for the physician (checking a box and faxing), satisfies Medicare’s requirements, and should ensure Medicare reimbursement, she says.


Previous post:

Next post: