Intentions MatterA consulting physician may perform diagnostic testing or initiate treatment as part of a consultation service (more on that to come), or may even take over the patient’s care at a later date, but the point of a consultation is always the same: With the consulting physician’s advice as a guide, the attending/requesting physician intends to continue to treat the patient. If the requesting physician intends for the consulting physician to assume immediate care of the patient’s condition, the service is not a consultation, but instead a referral or transfer of care. 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 patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.B). For instance, a pulmonologist sees a patient at the primary-care physician’s (PCP) request. The consultation request specifies, “Patient wheezing indicates that she may suffer from asthma. Please provide additional workup and your opinion on treatment options.” This service has a request and reason, and the PCP clarifies his wishes to continue to treat the patient for the possible asthma. If the pulmonologist responds with a written report outlining a care plan and possible treatment options, he has met all outpatient consultation requirements and may report 99241-99245, as appropriate to the documented service level. In contrast, consider this example: An ED physician treats a patient for a sprained ankle (845.01 Sprains and strains deltoid (ligament), ankle) by strapping (29540 Strapping; ankle and/or foot). The ED physician discharges the patient and advises him to visit an orthopedic clinic for follow-up. In this case, the orthopedist would not report a consult upon seeing the patient because the ED physician isn’t really seeking the orthopedist’s advice or opinion. When a physician assumes immediate responsibility for a patient’s care, you should report an appropriate inpatient or outpatient E/M service level. Do not report a consultation code to describe the visit—even if the service otherwise meets the consultation requirements.A Consult Can Include TreatmentRegardless of whether the consulting physician initiates treatment, CPT^® guidelines clarify that payers should recognize a consultation service as long as the visit meets all consultation criteria and no care transfer occurs. Medicare rules confirm this advice with the statement, “Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.” For example, a patient visits his PCP with chest pains consistent with unstable angina (411.1 Intermediate coronary syndrome). The PCP requests a consultation from a cardiologist to evaluate the patient and to provide treatment recommendations. The cardiologist performs a diagnostic heart catheter (for instance, 93510 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous), which showed minimal disease, writes a prescription for the patient, and prepares a letter with findings and recommendations for ongoing care. Although the cardiologist initiated care, the service meets all the consultation requirements and may be reported as such.Group or Specialty Physicians Can Request ConsultsCMS guidelines allow for same-specialty or same-practice consultations “when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.” CMS does warn, however, “A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.E). For example, an ear, nose and throat (ENT) specialist sees a patient who complains of left-side-only hearing loss (388.40 Abnormal auditory perception, unspecified). The ENT suspects an acoustic neuroma due to the single-sided nature of the problem, and requests a consultation with a neuro-otologist in the same practice. As long as the service meets all the consult requirements (request, reason, and report), the neuro-otologist may report the service with the appropriate outpatient consultation service code (99241-99245). Because same-specialty/practice consultations provide an opportunity for abuse, requesting physicians should clarify in the documentation that the same-specialty/practice consulting physician truly has a skill set the requester does not have. Otherwise, the payer may view such consultation claims as an abusive or fraudulent attempt to gain payment for an unwarranted service. Remember: If the specialist knows he or she does not have the skills or expertise to treat the problem, and is asking the subspecialist to handle that portion of the patient’s condition, then you cannot bill a consult for the subspecialist’s services. Rather, the service represents a transfer of care, and you would report the code for the appropriate inpatient or outpatient E/M service level. In an upcoming issue, we’ll report on general reporting guidelines and code selection for inpatient and outpatient consultation services.