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Can’t tell a consult from a referral? Read on
Comanagement arrangements create confusion in billing and coding
by Kristy Welker, CPC



Published in the May 2008 issue of Today's Hospitalist

IN LAST MONTH’S “By the Numbers” column, we looked at what goes into deciding whether to bill an initial hospital care code (99221-99223) or a consultation code (99251-99255). As we pointed out, many physicians are confused about how to distinguish between an initial visit and a consultation.

But it turns out that hospitalists are even more confused about what constitutes a consultation vs. a referral when they are asked to comanage a patient’s medical condition. With hospitalists increasingly taking on comanagement arrangements, this confusion is only going to get worse.

Let’s again
Hospitalists managing a condition postoperatively cannot bill a consultation code.

take a brief look at the definition of a consultation. A consultation is a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or provider.

Unfortunately, the Centers for Medicare and Medicaid Services (CMS) has stated that if a surgeon asks a physician or qualified nurse practitioner (NP) to manage a condition postoperatively, that request does not constitute a consultation, regardless of whether or not the physician or NP performed a preop evaluation.

Physicians and NPs providing management have to instead bill the appropriate subsequent hospital care code (99221–99223) in the hospital setting (or a subsequent nursing facility care code in a skilled nursing facility or nursing home). Unfortunately, those codes are paid at a much lower level than if you were billing a consult.

Crystal clear? Hardly. Fair? Maybe not. Let’s take a look at some readers’ questions.

I’d like to make sure that I qualify as a consultant if I am leaving recommendations for a requesting physician to follow. In the case where a patient has chronic conditions, the request is to review that patient’s existing medications for those conditions and to comment on whether medications should be adjusted (or if new ones should be added).

To me, this does not mean that I’m managing those conditions. Instead, the orthopedic surgeon remains the primary attending and he is managing the conditions based on my recommendations. Am I correct?


In the case where you are making recommendations for another physician to follow, your service is considered a consultation and you can bill a consultation code (99251- 99255). Check last month’s column, “The right way to bill consults,” for the documentation and language you need.

My hospital uses a comanagement model. Technically, that means that none of us provides a consult because everybody is comanaging, not rendering a specific opinion.

However, I think I should be able to bill a consult on a MI patient for whom I am managing poorly controlled diabetes mellitus, as requested by cardiology. Is this not the case?


Unfortunately, you answered your own question: Under a comanagement arrangement, you’re responsible for managing a poorly controlled condition, not for giving an opinion on how another physician should manage that condition. That management does not qualify as a consultation.

As far as Medicare is concerned, that is considered a referral. You as the receiving physician can bill a subsequent hospital care code, not a consultation code.

Is there such a thing as a transfer of care code that we can use when billing for comanagement? If so, how should we document those codes, and can every physician involved in comanagement bill one? If, for example, five physicians help comanage a complex case, can we each bill a transfer of care code?

Transfer of care is a term used by Medicare. A transfer of care occurs when a physician or qualified NP requests that another provider take over responsibility for managing the complete care of a patient’s condition. In such a situation, the original physician does not expect to continue to treat or care for that condition.

The problem is that there’s no such thing as a transfer of care code. Physicians or NPs who manage a patient’s condition need to document that transfer of care to their service in the medical record or care plan.

To bill, you’d use a subsequent hospital care code; physicians providing that service should document history, exam and medical decision-making. As for the five physicians in your example, each should bill a subsequent hospital care code—unless you have been asked to give an opinion on a condition. In that case, go ahead and bill a consultation code.

We have a post-operative joint replacement center, and the orthopedic surgeons request that all those patients undergo a hospitalist consultation postoperatively. (Almost all of the patients have a preop evaluation done by their primary care physician.) Can we bill that postop visit as an initial inpatient consult and subsequently bill for follow-up consults?

You’re using the word “consultation” here incorrectly. If it is routine for all patients to have a postop hospitalist “consultation,” then there is no specific reason your opinion is being sought. These postop visits therefore do not meet consultation guidelines.

Here’s a further clarification on your question: The CPT 2007 edition eliminated the term “initial” from the inpatient consultation codes, while the CPT 2006 edition deleted the follow-up consultation codes. That means that consultants can bill one consultation code only one time per admission. They must use subsequent hospital care codes for any follow-up visits made as a consultant.

If I discharge a patient from the inpatient service to the acute rehab part of the hospital and the treating physiatrist consults me again on the patient, am I allowed to code a new consultation on that patient?

Check with your local carrier for guidelines. My source, which is the Medicare carrier in Southern California, says that if the patient’s move to rehab actually constitutes a different admission, billing a consult code would be covered if you meet all other consultation coverage criteria.

However, it’s not always easy to determine if a patient being transferred from an acute care unit to a rehab unit in the same hospital is a different admission. According to my Medicare source, the consultation may be denied initially and have to be appealed. In any case, you may have to provide documentation to support a discharge from one unit and an admission to another.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.
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