Welcome Mark
You have properly defined a consult vs. a standard evaluation and management visit. However, note that Medicare doesn't accept consult codes, you have to use the regular visit codes. Some other payors will accept the consult codes, but pay the same rate regardless of whether you use the consult code or regular visit code. Having said that, there are other considerations...
Most surgical procedures, including most IR procedures, are identified as "global" services, meaning they include all of the normal pre- and post- procedure care for a specified period of time. You can download the CMS RVU zip files at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html, which includes a global indicator for the global period. The .pdf that comes in the zip file tells you how to decode the indicator.
If the global period does apply, then generally speaking, you can't bill for evaluation and management services (including consults) that occur the same day as the procedure, or during the global period, but there are exceptions. The most common exceptions would be if the decision to do the procedure (not just a normal pre-op clearance) was made during the consult/evaluation and management service, or in the case of some unusual complication or a visit focused on a significant problem unrelated to the procedure. You would have to use the appropriate modifier to indicate these circumstances.
If the global period doesn't apply (i.e. indicator XXX, or no procedure attempted), then you can bill the appropriate code for the consult service.
In my experience, in the vast majority of IR cases the patient is referred for a specific procedure (i.e. the decision has already been made), and the global period applies, so therefore, a consult/E&M service is not separately billable.
One more consideration is that billing significant numbers of evaluation and management services is likely to make your IR doctors lose their non-patient facing status for MIPS. I forget the threshold, but as I recall it's pretty low. If you elect to do MIPS as a group, depending on how many doctors in your group are doing e&m services vs. not, it could cause the group to lose non-patient facing status. It would be wise to assess this issue in terms of the potential future MIPS impact (additional expense to comply with EMR requirements or future Medicare payment reduction) vs. the revenue to be gained before going down this path.
It might be that you're part of an APM and not subject to MIPS, but even then, billing more evaluation and management services might result in APM patients being attributed to your doctors, even though they are only providing episodic care, which may not be desirable.
Hope this helps!
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David Smith FACMPE
Executive Director
United Imaging Consultants
Mission KS
(785) 393-8387
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Original Message:
Sent: 07-24-2018 09:07
From: Mark Leggett
Subject: IR Consult/FU Notes Billing
Good morning,
New to RBMA and I thank you in advance for any potential advice....
I have a question from our IR Dr's regarding billing for consults and FU notes. They currently do not bill for these and was hoping someone could shed a little light on that for us. I have researched and found that an IR consult:
- Requires an opinion or advice regarding the evaluation and management of a specific problem, and
- Is requested by another physician or other appropriate source.
I'm fairly comfortable that we can start billing for our consults but just wanting to see who may be doing this and looking for real world scenarios so I can confidently get them started.
Thank you for your help,
Mark
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Mark Leggett
Practice Administrator
Millennium Medical Imaging, PC
Albany NY
(518) 650-7503
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