Rowan University Office of Compliance and Corporate Integrity
Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) recently clarified the requirements for consultation services. The revised policy addresses when and by whom the initial consultation may be reported. By definition, a consultation service is distinguished from other evaluation and management (E/M) visits because it is performed by a physician or qualified NPP whose opinion or advice regarding a specific condition is requested by another physician or other appropriate source. Please remember the receiving provider (consultant) does not decide if the service is a consult. The requesting provider determines the service, based on whether a consult or transfer of care for a specific condition is needed.
A transfer of care occurs when a qualified provider requests that another qualified provider take over the responsibility for managing the patient's complete care of the condition and does not expect to continue treating or caring for the patient for that specific condition. In a transfer of care the receiving provider would report the service with the new or established patient visit codes according to the place of service and level of service performed and shall not report a consultation service.
Documentation requirements state a written request for a consultation from an appropriate source and the need for a consultation (i.e., the reason for the consultation) must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting provider and the consulting provider; however, the verbal conversation must be documented in the patient's medical record, indicating a request for a consult was made by the requesting provider. The reason for the consultation must be documented by the consultant in the patient's medical record and included in the requesting provider's plan of care.
A written report regarding the consultation must be furnished to the requesting provider. In the inpatient/outpatient setting in which a medical record is shared, the request and report may be documented in the progress notes. The request for the consultation may also be documented in the physician's orders when a medical record is shared. In the office setting, the documentation requirement must be met by a specific written request for the consultation and a written report documenting the communication back to the requesting provider.
Several consultation services were deleted by the American Medical Association (AMA) for 2006. Follow-up inpatient consultation codes 99261 - 99263 no longer exist. Therefore, follow-up consultations are now to be reported utilizing the subsequent daily care codes 99231 - 99233. Confirmatory consults also were deleted for 2006. A patient is not allowed to request a confirmatory consult or second opinion. If a patient seeks out a second opinion, report those services using either new or established E/M visit codes.
Also clarified in the policy revision is the use of NPPs for split/shared visits with the physician. The NPP or physician may not perform or report a consult utilizing a split/shared visit. If the NPP chooses to perform a consultation, the service must be billed under the UPIN of the NPP.
For the complete report from CMS, please click on Transmittal 788 below. For the complete report from the OIG, click on OIG 2006 Report below.