As a caregiver, we may notice subtle changes in our loved one’s health or behaviors that affect their quality of life. We need to talk to the primary care doctor who may suggest a second opinion or a consultation. We don’t want to start another line of care that may not be covered by Medicare and/or upset your current doctor. Will Medicare cover a second opinion or a consultation?
Yes, original Medicare will cover a second opinion and, in some cases, a third opinion.
The illness and subsequent care must be medically necessary. A second and third opinion must include a face-to-face meeting. The physician offering a second opinion must accept Medicare patients. (See CMS Transmittal 2282 August 26, 2011). Patients primarily request second opinions. Physicians generally request a consultation.
Typically, we want a second opinion when a course of treatment or surgery will have a substantial impact on our lives.
Most physicians, when asked, willingly offer names or clinics where a second opinion can be obtained. Typically, the first physician will share the original test results with the physician providing a second opinion.
The physician offering a second opinion may want additional diagnostic testing. Medicare will cover the additional tests as well. However, medical necessity must be present not only for the test but for the frequency of the test. Repeat tests may not be covered if frequency rules apply. A example is a screening mammography. Medicare only pays for one every two years. If the second opinion physician wants to repeat the mammogram, it would be deemed diagnostic. Medical necessity would be documented to support the subsequent mammogram. If the physicians don’t agree on the treatment, a third opinion may be needed. Medicare will cover this opinion as well.
Your physician may discuss your illness with a specialist and develop a plan. Medicare will not cover this physician-to-physician consultation as there wasn’t a face-to-face visit with the consulting physician and the patient. Our physician can use the work involved with this type of consultation to increase his visit work and code a higher-level visit to compensate.
What is the difference between a second opinion and a consultation you might ask?
Typically, a consultation is requested from a physician with a more focused scope-of-practice than our current physician has. As an example, I have diabetes treated by my family physician. But I develop kidney disease. I now need a physician who can treat the combination of the two acute illnesses.
A consultation is an exam that is requested by the treating physician rather than a second opinion as requested by the patient.
The consulting physician may assume care for specific elements of the treatment. A consultation results in a collaborative effort between my treating physician and the consulting specialist. A consultation code is billed. But there must be a face-to-face visit.
Why does all this matter, you might ask? Medicare cares. Medicare considers the work involved with new patients, established patients and consultations to be significantly different. Each of three visit categories generate a different payment based on the associated work.
- A consultation requires a physician request and report sent to the requesting physician. This service has the highest reimbursement.
- A new patient is one that has not been seen in the specialty clinic for more than three years by any physician of the same specialty. Most likely this code will be billed for a second opinion. This service has moderate reimbursement.
- An established patient is one where the patient has been seen in the last three years. This code would be billed if we have been a patient of the physician offering a second opinion. This reimburses at the lowest level.
Keep in mind, our physicians expend a good deal of time and expertise developing our plan of care. I am grateful for all of the specialists and family practice physicians who keep us well.
Written by Wanda Cantrell, RHIA, CCS, CCS-P, LPN
The column is based on Medicare guidance and reflects the views of the writer
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