December 1999 Bulletin

Medicare clarifies rules on consults

Revisions not adopted by all carriers yet, but provide appeal material

By Margie Scalley Vaught

The controversy over what constitutes a consultation may finally be coming to an end. With so many insurance carriers having their own definition of the components for a consultation, it has been hard for the physician offices to know when to bill for a consultation vs. a visit.

Over the years Medicare has found that many of their local carriers were processing consultations differently. This caused confusion in the appeal process when some physician offices dealt with multiple Medicare carriers. In August of this year, Medicare finally made a revision to their previous guideline of 15506 in the Medicare Carriers Manual. Along with this revision, several examples were given to help the carriers understand when a consult was billable and also when it was payable.

Even though this new clarification is just for Medicare carriers, it now, at least, gives the medical community some established guidelines and more accurate examples to remove some of the gray area in the field of consultations.

We all are clear on what is needed to justify a consultation:

These three areas do not seem to be where the problems arise.

There has always been the question as to whether or not the consultant can initiate treatment. In the 1999 CPT manual, the AMA tried to clarify some of this confusion by stating "A physician consultant may initiate diagnostic and/or therapeutic services." The AMA went on further to clarify the issue about assuming care during a consultation: "If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient's condition(s), the follow-up consultation codes should not be used."

It goes on to state that the initial visit would be coded as a consultation and subsequent visits would be coded using the appropriate subsequent inpatient or outpatient code. Further documentation from the AMA also has stated that a consultation still can be billed for even if a procedure is done, treatment is initiated and if the physician continues to see the patient.

For the complete details and examples regarding Medicare's revision of 15506 in the Medicare Carriers Manual, see the Medicare Carriers Manual Part 3, section 15506, Revision 1644, Health Care Financing Administration (HCFA), Department of Health and Human Services, August 1999, pages 15-81 through 15-83. This has not as yet been released on the HCFA web site.

It is important to remember that these revisions are technically for Medicare claims only and have not been adopted by all carriers.


Why are codes 11012 and 26951 considered bundled according to the "Correct Coding Initiative? Cathy Holland, Wasatch Orthopedic Clinic, Ogden, Utah


According to the Complete Global Service Data for Orthopaedic Surgeons book these two procedures can be billed together and are not considered "inherent" to each other. There must be good documentation supporting the excessive debridement that the surgeon is asking for with code 11012. Please remember that with procedure 26951 there is some debridement and irrigation that is "inherent" in the procedure. It is up to the physician to document that the amount of debridement was in excess of the normal amputation. If you are being denied routinely for this from payers, you may want to send a letter with a copy of the information from the AAOS's Global Service Data book. The Correct Coding Initiative edits change often, however there are not updates given except quarterly.


The October "Coding Corner" article states that if a procedure is done arthroscopically but no code exists in that section (only an open code), you should write your insurance carrier and tell them that you will bill the open code for a procedure done arthroscopically, with a modifier -22 or -52. According to AMA guidelines, this is incorrect. If there is no code for the procedure in the arthroscopic section of the CPT, you must use the unlisted arthroscopic code 29909. You may attach a note to the insurance carrier stating that the work is similar to the open code (for payment purposes). The AAOS CPT and ICD Coding Committee agrees with the AMA guidelines.

Margie Scalley Vaught, CPC, is an independent coding specialist and is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

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