Consult codes: (mostly) gone, but still a problem
Plus, how to bill discharges and ED services
Keywords: ICD-9 codes for consults, discharges and emergency room services
by Kristy Welker, CPC
Published in the July 2012 issue of Today's Hospitalist
EVEN THROUGH MEDICARE STOPPED using consultation codes a couple of years ago, I still get questions about those guidelines. Here are some recent questions, as well as several on how to bill for ED visits and for discharge services.
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Q: We have been going around and around with this for months and have not been able to get a clear answer: Is there a CPT code for inpatient consults?
I don't see any codes listed on the Centers for Medicare and Medicaid Services (CMS) Web site for these codes (99251–99255), and I've been told that the codes have been eliminated. But they are included in the "CPT 2012" book. I have been billing initial hospital visit codes (99221–99223) when I do consults.
|Both an ED doctor and a hospitalist can use ED codes for the same patient visit.|
A: Yes, the CPT codes for inpatient consultations are still 99251-99255, and the AMA's CPT book for 2012 still recognizes consultation codes. But the CMS eliminated the use of both outpatient consult codes (9924199245) and inpatient consult codes (99251-99255) as of Jan. 1, 2010.
According to the CMS, you should be using the initial visit codes (99221-99223) for any initial evaluation of an admitted Medicare patient. For your non-Medicare patients, however, you can still use the consultation codes listed in the CPT book if you provide a consult. Some private insurers are still paying them.
I have a question about inpatient consults done by primary care physicians. A patient was admitted by her OB, who then requested a consultation by that patient's primary care physician. Does the primary care physician bill an inpatient consultation code? I know that Medicare no longer recognizes those codes, so I assume the doctor has to use an initial visit code. Would that be the right way to bill?
Yes, for Medicare patients, doctors should bill an initial visit code (99221-99223) for the first evaluation, regardless of specialty. But if an OB is admitting this patient, chances are she's not covered by Medicare. If the primary care physician is billing the service to a payer that doesn't follow Medicare's guidelines on consult codes, then he or she should bill an inpatient consult code (99251-99255).
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I have a question about midnight admissions. I usually work as a nocturnist, and many admissions occur around midnight. Say I start seeing a patient at 11:30 p.m. and complete my assessment by 12:30 a.m. when I write the orders. The patient gets admitted on that second date. Should I bill for the time I start seeing the patient or when I write the admission order?
Your billed date of service should reflect your admission order, so that would be the second date in this case.
Often, my partner admits a patient and I see that patient later the same day for follow-up, documenting a face-to-face encounter and my time. May I document an extended time visit for the same day? And do I bill under my name or my partner's for that extended care visit?
Physicians in the same group practice and in the same specialty can bill only one visit per day whether it's an admission or a subsequent visit. So you should combine the services you both provided on that calendar day when selecting a level of service. Because your partner admitted the patient, the service should be billed under his or her name.
When a history and physical doesn't meet the requirements for a level 1 initial visit, may we use a subsequent visit code?
Yes, you may. If you don't perform the minimum requirements to meet the lowest level initial visit code (99221), I would suggest using a subsequent visit code (99231-99233). But opinions differ on this and, unfortunately, CMS guidelines don't address this specific scenario. So check with your local carrier for which code category to bill.
If an ED doctor sees a Medicare patient and refers the patient to the hospitalist, can the hospitalist charge an evaluation and management (E/M) level for outpatient services (new outpatient, 9920199205, or established outpatient, 99211-99215)? The patient was not admitted but transferred to another acute care hospital. And can both an ED physician and a hospitalist ever charge an ED visit code?
For Medicare patients, the hospitalist should use the emergency department codes (99281-99285) to bill services provided in the emergency room.
And yes, both an ED doctor and a hospitalist can use ED codes for the same patient visit. According to Medicare guidelines, "any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department." That's true even if the ED physician and the hospitalist bill an ED code on the same date.
If I see a patient in the ED but do not admit him and instead dictate a consult for the ED, what code should I use: ED visit, or office or outpatient consult?
For Medicare patients, use one of the ED visit codes (99281-99285). For non-Medicare patients, you could use the office or other outpatient consultation visit codes (99241-99245).
Say I discharge a patient April 1 but he is not physically discharged until the next day, and I see him briefly that next day. May I bill a discharge code on April 1 and a subsequent visit code (such as 99231) on April 2?
Yes, if you perform the elements of a subsequent visit code (99231-99233) on the day following the discharge. The insurer, however, may ask you for documentation to establish the medical necessity of that visit.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at firstname.lastname@example.org. We'll try to answer your questions in a future issue of Today's Hospitalist.