Consultation Codes – Overused?

A study published in this week’s Archives of Internal Medicine looked at so-called errors made in consultation code billing by specialists seeing patients at the request of a primary care practice in suburban Chicago. The methodology? Comparing the primary care office referral form with the specialist’s bill.
The author concludes that specialists are greatly overusing consultation codes in situations where a new patient visit would be more appropriate, to the tune of over half a billion dollars a year in Medicare payments, and suggests that it is time to reconsider the use of these codes. (Medicare, of course, has already come to the same conclusion, and beginning January 1 of this year, is no longer paying for consultation codes.)

There may be misuse of consultation codes going on, but this study does not necessarily prove that. The methodology does not include medical record review, the standard by which coding choices are verified or refuted, and relies entirely on the referring physician’s determination of what the specialist should be billing.

How does CPT define a consultation? It says simply this –

“A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source.”

Pretty vague, right? It is this vagueness that has allowed for the widespread use of consultation codes. Notice I said “widespread” and not “overuse”. One could argue that CPT’s is deliberately vague so as to allow specialist physicans to code consultations in a variety of clinical scenarios, which is in fact what they do. This is not necessarily “erroneous billing”. The term “overuse” implies fraud, and places blame at the foot of the specialist for our healthcare costs.

Medicare clearly does not want to pay for consultations anymore. We get that. But to imply that this is because doctors are overusing consultation codes or billing erroneously is to place blame on docs, rather than just admit that Medicare is looking for ways to shift payments towards primary care.

There is a genuine argument that the differential in specialist fees, based on the widespread use of consultation codes, is one of the forces driving docs into specialty care instead of primary care and that changing to payment schedule to give more dollars to primary care may begin to remedy the situation. The study’s author states this argument nicely –

Higher payment for consultation codes, while not adding a significant percentage to the overall Medicare budget, sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties. At a time when we want to encourage new physicians to consider primary care and support current practitioners, this differential sends adissonant message. Furthermore, as patients are increasingly responsible for out-of-pocket payments, it is difficult to explain to them why consultant physicians are paid so much more than their primary care physicians for the same or less time spent with them.

There is however, also a counter-argument that specialists incur additional years and costs of training that should be compensated in some way. It’s a complex issue without a simple answer, and both sides have valid points of view.

I happen to agree that we need to begin to create incentives for docs to enter and stay in primary care. However, the consequences of potentially losing subspeciality care, particularly in underserved areas, must be factored into any sudden major shifts in compensation.

I’ve said before that the good and bad news about healthcare is that the medical profession, in general, will follow the money, and that when financial incentives are aligned with what is right for patients, we all win. In realigning incentives, however, we must avoid using the blame brush to paint subspecialists as the bad guys in a system that has, until now, encouraged their practice by compensating them at higher rates than primary care.
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I just want to point out that I called this one when I predicted that the single health care reform item that would come this year would be that primary care would win a bigger piece of the pie at the expense of specialists.

10 Responses to Consultation Codes – Overused?

  1. …one of the forces driving docs into specialty care at the behest of primary care…

    and

    …primary care would win a bigger piece of the pie at the behest of specialists.

    At the risk of being labeled a syntax nazi, "behest" is the wrong word in these sentences.

    BEHEST: 1. a command or directive.
    2. an earnest or strongly worded request.

    I'm pretty sure you mean something more like "at the expense of…" Primary care is no more demanding that doctors enter specialty care than specialists are insisting that primary care care get a bigger piece of the pie.

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  2. Dino –

    Thanks you for your edits – I made corrections.
    This is why I shouldn't give up my day job….

    Other than that, what did you think?

    🙂

    Peggy

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  4. As a primary care doctor, I'm used to specialists making more for consults, but when they indicate it's at my request and then don't send me a report, well ….

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  6. Sorry; don't agree with your take. Yes, the study methodology wasn't very good for demonstrating what they wanted it to, but Consult codes are overused because "consultants" are overused, mainly because there are too many "consultants" and too few primaries. If specialists want to take care of all comers, they should make do with the same E/M compensation we do. If nothing else, maybe it will help us come together to demand appropriate payment levels for all of us.

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  7. I'm not sure we entirely disagree on this, Dino.

    I completely agree that we need to get back on track with primary care. I also think that the RVU system is not well done, and that we need to change the way docs are compensated so that time spent with patients matters.

    What I object to is the villifying of speicalists and the pitting of us docs against each other, primary care vs specialists.

    Calling consult codes "overused" is one way of changing the conversation from "how do we fix healthcare " into " it's all the fault of the doctors".

    Those who are making the most profit out of healthcare love it when we docs start fighting amongst ourselves – it leaves them free to go after the real money.

    Love ya'
    🙂

    Peggy

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  9. Great post. CMS made the guidelines so easy to call any new visit a "consultation" so of course the specialists will use that higher paying code. They have just been following the arcane rules that make no sense. While it may be unfortunate for them that consultation payment is now gone…I do agree with dino that it is long past the time to rationalize payments for primary care. I often spend far more time on a patient care visit than a specialist does for a single issue that he bills as a "consult".

    I took my young son to a urologist once (a friend also) and he billed the insurance a full "consult" for the visits, including the follow up. The problem was simple, the time spent was minimal and he was paid a S—tload of $$. I knew then that primary care was screwed.

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  10. What's interesting here is no one seems to recognize that the reason the specialist gets the consult is because it's requested by the primary! Why? They need someone more knowlegable or with more experience with a particular aspect of a patient under their care, thus they're calling in help for their patient. Why shouldn't the specialist get paid for that? Why, depending on the level of consult, shouldn't the specialist get paid MORE than the primary that asked for his/her help? If the primary could do it on their own, why didn't they just do it?

    Reply

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