Published in the July 2009 issue of Today’s Hospitalist
WE’VE TACKLED THE TOPIC OF CONSULTATIONS BEFORE, but there still seems to be a great deal of confusion about how to distinguish between “and bill for “consultations as opposed to transfers, admissions and comanagement. To unravel the tangled rules on this controversial area of billing and documentation, I’ll answer some questions from readers.
Q: I’m still confused about inpatient consultations. Usually, specialists write requests as follows: “Consult hospitalist for …” What typically goes in that blank is “diabetes,” “diabetes management,” “hypertension” or “UTI.” The requesting physician usually expects us to follow those patients and address that portion of their care.
After such a request, I consider my first visit a consult and bill it as such, then bill subsequent visits with subsequent visit codes. However, I’m hearing that it may not be appropriate to bill the initial encounter as a consult in this situation. What do you think?
A: Guidelines define a consultation as a service provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or provider.
If, as you stated, the request is to “follow” a patient, this wouldn’t qualify as a consult. Instead, it sounds like a comanagement scenario where you are managing a particular condition. Because you are probably not the admitting MD, use subsequent visit codes (99231-99233) for all your visits with these patients, including the first one.
Q: A patient who presented to the emergency room was examined by the ED physician and transferred to labor and delivery to be evaluated for abdominal pain. Our OB hospitalist evaluated and counseled the patient, then arranged for her to be transferred to a different hospital where her own physician would evaluate her further. Can we bill this as a consult for the OB hospitalist?
A: This sounds like a transfer, not a consult. The patient was handed off from one department to another, and I don’t get the impression that the “laborist” was expected to follow up with the ED doctor with an opinion on treatment. Remember, a key element of a consultation is that the requesting physician retains control of the patient’s care.
If, however, the OB hospitalist was called down to the ED to give an opinion on what treatment was needed, it could have been a consult and billed as such.
Q: Our general and orthopedic surgeons are asking hospitalists for consults, and we turn some of the work of those consultations over to our midlevels. (Several are PAs, and one is an APRN.) The hospitalists see these patient later, document with an additional note and then bill for the consult. Is this correct? If not, how should we be billing?
A: If you are billing this split service for a Medicare patient with a consultation code (99251-99255), that would not be correct. Medicare does not allow consults, critical care or procedures to be billed as a split or shared visit between a physician and a midlevel.
And if you are billing Medicare for the consultation, only that portion of the visit that the physician performed and documented would count toward determining the level of consult you can bill. You may want to consider having only the MDs work on consults. For non-Medicare patients, check with your insurers for guidelines.
Q: How should I bill when a patient is transferred from the ICU and I assume care from the intensivist? Is this a consult or a subsequent visit, and is there anyway I can get reimbursed more for an ICU transfer? Is there language I can use to make this a consult or a new patient, or should I simply add a prolonged service code to subsequent visit codes?
Keep in mind that these are sick patients coming out of the ICU who I have never seen before on this admission.
A: You’re being asked to completely assume care, so this would not qualify as a consultation. And inpatients cannot be broken down into new and established status.
Use subsequent visit codes (99231-99233), but because these patients are coming from the ICU, you can probably qualify for the 99233 level. To decide whether you can use an extended service code as well, see “The ins and outs of prolonged service codes” in the May 2009 issue of Today’s Hospitalist.
Q: A colleague of mine claims that if a nephrologist and a hospitalist see the same patient on the same day, both doctors should not use the same primary diagnosis when billing. According to my colleague, the nephrologist should list renal insufficiency as the diagnosis, for instance, while the hospitalist should use another diagnosis such as diabetes. Can the hospitalist use the same primary diagnosis as a specialist seeing the patient the same day?
Here’s another example: A patient comes in with a fracture. The hospitalist first sees the patient and uses the fracture as the primary diagnosis. Then the orthopedist sees the patient and likewise uses fracture as the primary diagnosis code. This may be two evaluation and management services on the same day, but the physicians are not in the same group.
A: Each physician must submit the diagnosis for the condition(s) he or she addressed in that particular visit. If the hospitalist’s main reason for seeing the patient was fracture care and not diabetes, for example, that should be the primary diagnosis. But if the patient’s diabetes is the main reason why the hospitalist saw the patient at that visit, diabetes should be the primary diagnosis.
You’re correct that it helps when physicians can list different primary diagnoses for visits to the same patient on the same day. When two physicians submit a bill for the same day, diagnosis and patient, insurers may question (or even deny) the medical necessity of one of those visits. If both doctors address (and list) the same diagnosis, their documentation needs to justify why both services were medically necessary, regardless of their specialty.
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.