Billing Compliance Guidance: Consultations
Professional billing for consultations remains under the Medicare microscope. Not long ago, a nationwide audit by the Office of Inspector General (OIG) found that an extremely high percentage of consultations are miscoded. This area continues to be one where Medicare reports a high-paid claims error rate every year and where CMS recently issued some significant documentation requirement changes. The main issue concerns physicians who bill for consults when the actual intent of the requesting physician is that they take responsibility for managing the patient’s care.
Consultation services are distinguished from other evaluation and management services in that consultations are services to provide an opinion or advice regarding a specific problem at the request of another clinician. To qualify as a consultation, the medical record must reflect evidence of this request and written communication or report of the results of the consultation back to the requestor. The documentation of the intent and request for consultation must be reflected in both the consulting physician’s record and in the requesting physician’s record. After the consultation is complete, the patient is returned to the originating physician for management of the condition or together the decision is made that the consulting physician is better suited to treat the patient
A consultation should not be billed if the requesting physician is clearly transferring the care of the patient to the receiving physician. With a transfer of care, the referring physician is not asking for the specialist’s opinion or advice, and does not expect to continue to treat the patient for that condition. When care is transferred the treating physician should bill the initial encounter as a new patient visit.
Questions? Call the Billing Compliance Office at 617-582-0090.