Practice Economics

The Admission Consult


 

When consultation services occur in inpatient and outpatient settings, physicians report the code category that best corresponds to the patient’s registered status at the time of service:

  • Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or
  • Outpatient consultation (99241-99245) for services provided to an outpatient (office, emergency department [ED], or observation care).

Regardless of location, consultants must meet each requirement before submitting a claim for these services. This article focuses on the coding and billing nuances of inpatient consultation services; outpatient consultations provided in the ED or during observation care will be addressed in a future issue.

Code of the Month

ADMISSION CONSULTS

99251: Inpatient consultation, which requires these three key components:

  • A problem-focused history;
  • A problem-focused examination; and
  • Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limiting or minor. Physicians typically spend 20 minutes at the bedside and on the patient’s hospital floor or unit.

99252: Inpatient consultation, which requires these three key components:

  • An expanded problem-focused history;
  • An expanded problem-focused examination; and
  • Straightforward medical decision-making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

99253: Inpatient consultation, which requires these three key components:

  • A detailed history;
  • A detailed examination; and
  • Medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

99254: Inpatient consultation, requires three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision-making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

99255: Inpatient consultation, which requires these three key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision-making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

These codes are used for new or established patients (those who have received face-to-face services from a physician or someone from the physician’s group within the past three years). The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital care code. Time is only considered when more than 50% of the total visit time is spent counseling/coordinating pat­ient care. See Section 30.6.1C, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf for more information about reporting visit level based on time.

The Three R’s

Reason and request: Consultants (physicians or qualified non-physician providers) are asked to give an opinion or recommendation, a suggestion, direction, or counsel in the treatment of a patient’s condition because the consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.

The requesting professional must be a physician or other qualified healthcare provider (e.g., nurse practitioner, physician assistant, resident acting under guidance of a teaching physician) currently involved in the patient’s care. Do not report consultation codes when a patient, family member, or third party requests a second opinion. Instead, select the most appropriate subsequent hospital care code (99231-99233).

The request must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting provider and the consulting physician; however, when this occurs, the verbal conversation must be documented by both the consultant (in the progress note) and the requesting provider (in the plan of care or as a written order). Standing orders for consultation are prohibited. Clearly document the reason for the service: the patient’s condition, sign, or symptoms that prompted the consult request, ensuring the medical necessity of the service.

Try to avoid terminology, such as “Consult hospitalist for perioperative management.” This leads to the payer’s confusion about co-management issues. The documentation should reflect the true intent of the service: “Consult hospitalist for perioperative risk assessment.” If necessary, ask the requesting provider to clarify the request. The consultant should further explain the request in his/her own note.

Report: After the patient’s assessment, the consultant documents the service and prepares a written report for the requesting provider, which includes the written request, consultation evaluation, findings, and recommendations.

It is appropriate for the consultant to initiate diagnostic services and treatment at the initial consultation service or at a subsequent visit, yet still qualify as a consult. In the inpatient setting, it is acceptable for the consultant’s report to appear as an entry in the shared medical record without need to forward a separate document to the requesting provider.

Code Use

Inpatient consultation codes are reported once per hospitalization. If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99251-99255 are denied. This happens even when the consultant signs off and is re-consulted for a different problem during the same hospitalization.

A physician who provides patient services after the initial consultation reports subsequent hospital care codes 99231-99233 for each date in which a face-to-face encounter occurs.

A physician or qualified nonphysician provider may request a consultation from a member of the same group practice as long as the consultant possesses a legitimate expertise in a specific medical area beyond the requesting professional’s knowledge (e.g., a hospitalist may consult a member of his group who specializes in infectious disease).

This situation is likely to produce a rejected consult claim. In appealing the claim, submit notes from each member of the group (i.e., the requesting provider and the consultant) to demonstrate medical necessity and distinguish the expertise involved in each service. Medicare and payers who follow Medicare guidelines should reimburse the consult after the documentation is reviewed.

Co-management

Preoperative consults: Preoperative consultations are permitted when performed by any physician or qualified nonphysician provider at the request of a surgeon—as long as all requirements for performing and reporting the consultation codes are met. The service must be medically necessary and not provided for routine screening (i.e., consults for healthy patients scheduled for elective surgery).

Postoperative management: If a physician or qualified nonphysician provider who has performed a preoperative consultation is subsequently consulted and/or assumes responsibility for the complete or partial management of the patient’s condition(s) during the postoperative period, the appropriate subsequent hospital care code 99231-99233 is used.

Additionally, do not report consultation codes when the surgeon asks the hospitalist to take responsibility for the management of an aspect of the patient’s condition during the postoperative period (i.e., consult for postoperative management). In this situation, the surgeon is not asking the consultant for an opinion or advice for the surgeon’s use in treating the patient, and the surgeon is not expected to continue on the case. This constitutes concurrent care and is billed with the appropriate subsequent hospital care codes.

Alternately, the surgeon may continue on the case, not transferring the care for the remaining portion of the hospitalization to the hospitalist, and incorporating the hospitalist’s recommendations into his/her own care plan, subsequently retaining the hospitalist’s services in assisting with care. Because the transfer did not occur prior to the consultation, this situation may constitute an inpatient consultation and be reported as such.

Unfortunately, some local Medicare contractors do not recognize this latter distinction and prohibit reporting post-surgical involvement with 99251-99255. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

Code These Cases

Case 1: A surgeon admits a patient for a fractured hip. This 75-year-old white female has a longstanding history of hypertension and chronic obstructive pulmonary disease (COPD). Upon admission, the patient’s blood pressure is significantly elevated with (self-reported) elevated readings over the past week. The surgeon requests a consult for assessment and treatment of uncontrolled hypertension. What service(s) can the hospitalist report?

The Solution

The surgeon requested the hospitalist’s opinion regarding uncontrolled hypertension. The request is documented in the medical record, the hospitalist performs the evaluation and documents his recommendations. Given the nature of the patient’s condition, the hospitalist initiates treatment and remains on the case. The hospitalist reports the appropriate level of consultation (99251-99255) with the codes ICD-9-CM 401.9 (essential hypertension, unspecified) and 496 (COPD, not otherwise specified).

Case 2: The patient in the first case is medically stabilized and the surgeon proceeds with surgery. Postoperatively, the patient’s COPD begins to flare as her respiratory status is compromised by the anesthesia. The surgeon requests the hospitalist’s advice on the postoperative management of the patient’s COPD. What service(s) can the hospitalist report?

The Solution

Because the hospitalist provided preoperative care to the patient, only subsequent hospital care codes 99231-99233 with 496 (COPD, not otherwise specified) and 401.9 (essential hypertension, unspecified) for the postoperative involvement may be reported, even though the consult is requested for different problem.

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