Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.
Objectives of the article include answering the following questions:
- Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
- Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
- Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
- Can two internists (same specialty) treat and bill the same patient on the same day?
- What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?
An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:
Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)
Inpatient consultant services are coded using initial consult codes (99251-99255).
Scenario # 1
A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.
Question # 1: Should this be coded as a consultation or a subsequent visit?
Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—