Creative Consulting

One of the least logical aspects of our dysfunctional payment system for medical care is that I get paid more if another doctor asks me to see you than if you come to see me of your own accord. In the latter case, the visit is considered an "Evaluation and Management" service, but if another doctors asks -- in writing -- for my opinion and if I convey that opinion back to him -- in writing -- then the encounter is considered a "Consultation." What's the difference? Benjamins.

This is one of the major mechanisms used by specialists to enhance their income. Whenever they ask who your primary physician is, they use the information to compose a letter that begins,

I saw Mrs. Munchausen in consultation at your request.

even if I never asked Mrs. Munchausen to see them and in fact wouldn't trust them to care for my dead dog. Technically, because my "request" isn't in writing, they are supposed to be billing for an E/M service instead of a consult, but because oversight of this technicality is sparse to say the least, they continue to do it with impunity.

On the flip side, surgeons not infrequently request my opinion about the medical conditions of our mutual patients prior to subjecting them to whatever interventions their little surgical minds can dream up. They call this "Medical Clearance" and, when the patient has an actual medical condition, it is legitimate. The ritual pre-operative History and Physical, interestingly, is not the same. Surgeons also went to medical school, where I know for a fact they all learned how to do H&Ps. Additionally, they are being paid for them as part of the global fee for the surgery. I have blogged about this before.

Still, there are certain surgeons and hospitals who continue to insist that I complete certain forms pre-operatively. To assure that I am within the letter of the law for billing the visit as a consultation, I have developed a form that I fax to the referring surgeon prior to the patient's visit to me. Here is what it says:

Dear Dr. Halstead,

Please confirm that you have requested a medical pre-operative evaluation of the above named patient by completing the following information within 48 hours to avoid delay in preparing our patient for surgery.

The form then has spaces to fill in the proposed surgery and diagnosis. Then there is a line that states:

Specific medical reason (UNRELATED TO THE SURGERY) for medical clearance:

I can't imagine being more explicit than that. The form closes with spaces for the surgeon to request pre-operative blood work and other studies, if he wants me to do them. There is also a place for the referring provider's NPI, which I need for billing.

You would be amazed at what appears on that line for "specific medical reason":

• Hypertension (anyone who has checked off "blood pressure" on their two-page review of systems form)
  
• Diabetes (ditto)
  
• Heart disease (includes anyone who has ever had a heart attack, thought they had a heart attack, or seen a cardiologist)

Many of those are valid, and I am happy to confirm for the surgeon that the stated medical conditions are stable (even though the information is easily and quickly available from the patient.)

• Anxiety
• Depression
• Bipolar

Um, excuse me but what does this have to do with surgery? Everyone is anxious about going under the knife, and the reason they need to do so is often something pretty depressing. Yes, people with major psychiatric illnesses sometimes require surgery, but the mental illness rarely has anything to do with the surgical issues.

• Arthritis (for joint replacements)
• Gall stones (for removal of the gallbladder)
• Hernia (for repair of the hernia)

Hello? What part of the (capitalized) statement "NOT RELATED TO THE SURGERY" didn't

But far and away the most frequent are the most useless:

• Cosmetic
• [blank]

What's a poor Dino to do?