Rule changes for referral documentation create confusion

Physician organizations have asked CMS to clarify the rules and have requested that the agency eliminate its requirement of additional paperwork for consultation billing.

By Pamela Lewis Dolan, AMNews staff. July 9, 2007.

The Centers for Medicare & Medicaid Services implemented changes late last year which now require even more documentation, both from the referring physician and the consulting physician, for a doctor to bill for a consultation instead of the lower-rate E&M visit. Some private insurers have already taken CMS' lead and have implemented the same changes.

But physicians still are confused over what constitutes enough documentation. The American Medical Association and 51 other medical societies sent a letter to CMS asking for clarification, as well as requesting the agency to drop its request for more documentation for a consultation code.

The confusion has doctors who are seeing referred patients trying to find ways to get appropriate documentation so they can be paid for a consultation, and doctors doing the referring complaining about not getting any extra payment for any effort to create that documentation.

"When I occasionally send someone out, I have a scratch pad with my name on it saying please see this patient about such and such and ask the patient to give it to the doctor," said Steve Craig, MD, a dermatologist from Coeur D' Alene, Idaho. "Hopefully that covers me and the person who does the consultation."

But the problem, he says, is when he is asked by another physician to do a consultation, he has no way of knowing whether the referring doctor has included the proper paperwork in his own files. And if the paperwork is not included in the referring physician's file, it would be Dr. Craig who is penalized, and possibly audited, for billing a consultation code without documentation.