E/M issues continue to plague physicians

Q I am having a disagreement with an insurance company concerning coding of the consultation codes and need your advice.

The Derm Coding Consult of the American Academy of Dermatology Association states on the issue of transfer of care, "Total care of a patient is rarely, if ever, transferred to a dermatologist. The dermatologist may take over the care of a certain condition, such as psoriasis, but not the total care of the patient. Therefore, transfer of care is not usually an issue for dermatologists when reporting consultation codes."

Additionally, CPT's guidelines on page 14 of the 2006 CPT book published by the American Medical Association states, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."

What do you think? Your thoughts on this would be much appreciated.A in New England

A Section 30.6.10 of Medicare's Claims Processing Manual addresses new regulations regarding the appropriate billing of consultations. The revised regulations became effective January 1, 2006, with an implementation date of January 17, 2006.

Under Section 30.6.10B entitled, "Consultation Followed by Treatment," the following instructions are provided:

"A physician or qualified NPP (non-physician provider) consultation may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs."

So let's look at exactly what this portion of the regulations states. It states that:

1. A physician or qualified NPP may initiate diagnostic services and treatment at the initial consultation service or subsequent visits.

Okay. So a dermatologist can have another physician send a patient to him/her for his/her advice and opinion regarding a specific problem, can initiate diagnostic or therapeutic service and still bill it as a consultation.

The dermatologist can also provide diagnostic or therapeutic services at subsequent visits after the initial consultation. This certainly implies that the dermatologist may continue to see the patient and still bill the initial visit as a consultation.

2. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service.

Okay, this implies again that the dermatologist can continue to see the patient after the initial consultation, but that these visits must be billed as established office visits (e.g., CPT codes 99212 to 99215), if provided in the office setting, follow-up inpatient hospital visits (e.g., CPT codes 99213 to 99233), if provided in the inpatient hospital setting or subsequent nursing facility care visits (e.g., CPT codes 99307 to 99310), if provided in the nursing facility setting.

3. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.

According to Section 30.6.10B, A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP takes 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.