Rules for consultations have changed. Or have they?

The transmittal, along with its examples, has caused significant confusion, even for me. To be sure I had the best information available, I sought clarification of the changes from both the national CMS office and CMS's Denver regional office.

First I will discuss the major changes as published in the transmittal and give a strict interpretation of the rules. Then I will discuss the interpretations as I understand them and provide suggestions on when to charge a consult and when not to charge a consult.

Analysis: What this all means

As you probably know, there are three parts to any regulation: the regulation, the interpretation of the regulation, and the implementation of the regulation. Unfortunately, Medicare rules and regulations have many interpreters, including the central CMS office, each regional CMS office, and each of the Medicare carrier medical directors.

The following text was copied from the transmittal (Requirement #4215.17):

"Carriers shall instruct physicians and qualified NPPs that a consultation request may be verbal. However, the verbal interaction identifying the request and reason for a consult shall be documented in the patient's medical record by the requesting physician or qualified NNP, and also by the consultant physician or qualified NPP in the patient's medical record. A consultation request by the requestor may be written on a physician order form in a shared medical record."

This interpretation would indicate that the documentation must be in both the requesting physician's and the consulting physician's charts. The most rigid and strict interpretation would be that a consultant is required to read the other physician's medical record, obtain a written request, or have a confirmation that the requesting physician has documented the request in his chart. It would indicate that a CMS audit of a consultation could include analysis of the requesting physician's record. Although problematic, this could be done, and it leaves the consultant physician at risk of losing a consult charge even if all their "i"s are dotted and "t"s are crossed.

I spoke with Bill Rogers, MD, director of the Physicians Regulatory Issues Team at CMS. I specifically asked him if a consulting physician is required to have confirmation that the requesting physician has the proper documentation in his chart.

"That was not the intent of CMS," Dr. Rogers told me. "CMS understands that would be a lot of wasted time on the part of the physician and their offices as well as CMS in trying to verify the requesting physician's documentation or to require a written request for a consult."

Although his office was not the one that published the transmittal, he indicated that there was a move to change the phrase "and also" to "or" in the transmittal. If that occurs, it will remove any controversy about the need to confirm the documentation in the referring physician's chart and kill forever the idea that a written request is necessary.