ACP: Governmental Affairs and Public Policy - ACP Advocates Changes in Consultation Policy Regarding Transfer of Care

Advocacy

ACP Advocates Changes in Consultation Policy Regarding Transfer of Care

August 14, 2006

Mark B. McClellan, MD, PhD
Administrator
Centers for Medicare and Medicaid Services
7500 Security Blvd
Baltimore MD 21244

Dear Dr. McClellan:

The American College of Physicians (ACP), representing over 119,000 physicians specializing in internal medicine and medical students, requests that a change in regulations be made to the requirements for consultations (Medicare Claims Processing Manual 30.6.10). ACP requests two changes to the regulation, which are summarized below. In addition, the specific wording changes we recommend to the 30.6.10 manual language is listed in the attached using underline—to indicate added text—and strikeout—to indicate deleted text.

The first change modifies the transfer of care requirements to more closely match the term used by practicing physicians and corresponding to the earlier definitions of a transfer of care in previous editions of the Medicare Claims Processing Manual. The second change would allow physicians who performed preoperative consultations to bill for consultations for postoperative conditions that are different from the preoperative consultation.

ACP recommends that CMS change its definition of transfer of care so that a transfer of care is recognized only when one physician contacts another and they agree that the patient would better be treated overall under the new physician. The regulation’s stipulation that a transfer of care occurs when one physician transfers any aspect of a patient’s care to another fails to reflect current practice. Physicians are frequently in the position of ordering consultations on their patients when they believe the advice or opinion of another physician is needed to provide the sufficient expertise to diagnose or treat the problem. These experts would then by nature take over the element of a patient’s care. Asking the physician to give up a significant payment merely because he has identified that the patient needs immediate treatment is not appropriate. This policy could potentially lead to increased utilization, as patients require both a consultation and a subsequent visit to receive the same care that is today completed with a consultation. CMS has long advocated that physicians should be paid appropriately for work, and this new transfer of care provision prevents appropriate payment for work. This would increase costs and greatly harm patient care.

In addition, ACP recommends that CMS change its regulations to allow physicians who perform a preoperative consultation to bill for a new inpatient consultations for postoperative conditions that are different from the preoperative consultation condition. When a consultation is ordered, the ordering physician identifies for the other physician what he or she is concerned about and asks the physician to identify the issue related to that problem. Current Medicare policy prohibits a physician who has completed a preoperative consultation from billing for a consultation after the completion of the operation. This is inconsistent with other Medicare policy on consultations, which allows a physician to bill for a consultation as long as it is for a new problem. The issues that a physician addressed during a preoperative consultation may be completely different from those issues addressed after the operation. For example, a physician may see a patient for inhaler changes and steroid recommendations at a preoperative consultation and be asked to address respiratory failure postoperatively. The work completed by the physician in this postoperative consultation is as intense and time-consuming as it would be if the physician had not completed the preoperative consultation and the payment should reflect this. The suggested changes that are attached would fix this inequity.

ACP believes that these two changes are great strides in increasing the consistency of the consultation guidelines. If you have any questions, you may contact Brian Whitman, Senior Analyst, Regulatory and Insurer Affairs at (202) 261-4544. Thank you for your consideration of these recommendations.

Sincerely,

Joseph W. Stubbs, MD, FACP
Chairman, Medical Service Committee

Cc: Herb Kuhn, Director, Center for Medicare Management