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Ask-A-Consultant: Billing for In-house Consultations

Q:

We have a new physician in our practice. His specialty is Cardiology but he is the only physician in our practice of five cardiologists that can perform Electrophysiology services and Coronary Ablation. If one of our other cardiologists has seen a patient in the recent past but wants our new physician to see the patient for review for EP services, can that be billed as a consultation? I say no since he is in the same practice and the same specialty but another employee says yes since he is the only physician in the practice that can do EP services.

A:

In response to this question, I would refer to the Medicare Carrier Manual Part III, Chapter XV – Section 15506. “CONSULTATIONS (Codes 99241 - 99275).”   This manual provides guidance to the local Part B Carriers on how to pay for physician services and provides the parameters for allowing such in-house consultations. It first gives the criteria for a service to be considered a consultation rather than a new patient visit (emphasis added):
“Consultation Versus Visit.--Pay for a consultation when all of the criteria for the use of a consultation code are met:
  1. Specifically, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician, or other appropriate source (unless it is a patient-generated confirmatory consultation).

  2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient’s medical record.

  3. After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.”
Next, the guideline for in practice consultations state:

“Consultations Requested by Members of Same Group.--Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met. (See §§15506A and 15501.H.)”

Finally, the Manual gives an example of when payment would be made for such a consultation. Specifically, a general ophthalmologist diagnoses a patient with a retinal detachment, and sends the patient to a retinal subspecialist to evaluate the patient because the general ophthalmologist does not treat this specific problem. After evaluation, the retinal subspecialist sends a report to the referring physician explaining the findings and treatment options, and schedules surgery. The example does not state that the subspecialist must be outside the group practice.

Correct documentation is your key to justifying an in-house consult, if questioned by a payor. The emphasis is on documented need for a level of clinical expertise that the referring physician does not possess. Would other general cardiologists in your community use your subspecialist as a consultant for specific problems? If a common medical records is used, make sure the referring physician has documented his/her request for the consult & why in the record. The request must be for the evaluation of a condition, and advice on treatment, not a request to assume management of a diagnosed condition.

The consultant also be able to document that he/she met the criteria for all three areas of a consultation for the in-house referral as he would for a referral from outside the practice (performs a clinically appropriate history, examination & level of medical decision making, etc.). Even with a common office record, the consultant should send a formal report to the referring physician in the same manner that he/she would for an outside referral. Any subsequent visits to the consultant by that patient would be considered an established patient visit.
 

Karen M. Beard, CPC
Senior Associate

MMA does not provide legal, accounting, or tax advice.  If you need assistance in these areas, we recommend that you consult a qualified professional.  In addition, please note that a client relationship with MMA is not established by the submission of a question to this forum or by the publishing of MMA's response.



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