New Guidance Related to the Consultations Codes
By: DAVID M. GLASER
January 2006
CMS (The Center for Medicare and Medicaid Services) issued a transmittal that instructed its Medicare carriers to implement changes to the policy regarding consultations as of January 17, 2006. At first glance, the transmittal appears to dramatically limit the definition of a consultation. However, a more careful reading suggests that in fact, with the exception of the deletion of the confirmatory consultation and follow-up inpatient consultation codes, physicians need not significantly change their practice.
There is one change in the transmittal that seems, upon initial review, to suggest that it is nearly impossible for a visit to qualify as a consultation. CMS has always said that when a transfer of care occurs, the visit does not qualify as a consultation. However, the new guidance changes the definition of “transfer of care.” The new definition reads: “A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients' complete care for the condition and does not expect to continue treating or caring for the patient for that condition.”Prior to this change a transfer of care was defined as the consultant taking over complete care of all of the patient’s medical needs, not just the problem for which a consultation was requested. (The new definition is similar to the definition CMS used prior to 1998.) If that were the only text in the transmittal, it would be reasonable to conclude that many visits that have been considered consultations would not qualify because the requesting physician anticipates that the consultant will be primarily responsible for handling treatment of the problem. However, a review of the examples CMS includes in the transmittal suggest that if the requesting physician will be monitoring the patient for reoccurrence or to facilitate or evaluate the treatment in any way, then the visit still qualifies as a consultation.
The transmittal includes several examples of visits that should be considered consultation.
The first is:
“An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. He identifies a questionable skin lesion and asks a dermatologist to evaluate the lesion. The dermatologist examines the patient and decides the lesion is probably malignant and needs to be removed. He removes the lesion which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his evaluation and treatment of the patient. Modifier -25 shall be used with the consultation service code in addition to the procedure code. Modifier -25 is required to identify the consultation service as a significant, separately identifiable E/M service in addition to the procedure code reported for the incision/removal of lesion. The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist.”
In that example, the dermatologist diagnoses and removes the lesion, so someone might try to argue that the dermatologist, rather than the internist is following the condition. But the example makes it clear that the fact that internist will continue to monitor the skin means that the initial visit qualifies as a consultation. Similar examples discuss care by a cardiologist and general surgeon.
There is an additional example in the newsletter that addresses the ongoing debate as to whether visit following an emergency room visit can qualify as a consult. CMS is taking the position that most of the visits do not qualify as consultations. They use the following example:
“The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code.”
While CMS does not address it, there seems to be no doubt that if the ER physician requested a specialist come to the ED to examine the patient, that visit would qualify as a consultation.