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Clarification of Consult-Code Usage


 

Dr. Hospitalist

In July, I was CC’d on an email from a reader that asked for further explanation of billing for patients in the ED. I mentioned briefly in the May 2012 issue of The Hospitalist that, in the ED, a consult on a patient that ends up being sent home can be billed with CPT code 99281-99288. Another author for another hospitalist publication had previously written that hospitalists do not have consultation codes for patients evaluated in the ED, then sent home. The reader basically wanted to know how to bill for this encounter.

It should be noted that this is billing for a visit in the ED for which the patient is not admitted. It is not a consult code, as those effectively have been eliminated from the CPT manual.

Here’s some further explanation:

Effective Jan. 1, 2010, the Centers for Medicare & Medicaid Services (CMS) eliminated the use of the codes 99241-99245 (outpatient consultation) and 99215-99255 (inpatient consultation) for use with Medicare Part B beneficiaries. Those codes are now either 99201-99205 (office outpatient visit) or 99221-99223 (initial inpatient visit).

Although this might seem confusing, CMS actually made it simpler. If you or your group is seeing a patient for the first time, as either an admission or an inpatient consult, you use the 99221-99223 codes. So now there are three codes to use instead of eight. Just to note, though, this applies specifically to Medicare patients.

It should be noted that this is billing for a visit in the ED for which the patient is not admitted. It is not a consult code, as those effectively have been eliminated from the CPT manual.

Similarly, if you evaluate a patient in the ED and they are not admitted to the hospital, then you use the 99281-99288 codes. Yes, these are the same E/M codes that the attending ED physician will use for their care. If you personally evaluate the patient in the ED, document as required, and if the patient is admitted, then it reverts back to the 99221-99223 codes. However, if the patient does go home from the ED (never admitted as an inpatient or under observation status), then you use the 80s codes referenced above.

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Just to add one more layer of complexity, please remember that there are specific codes for patients admitted under observation status (99217-99220), as well as for patients that are admitted and discharged in the same calendar day (99234-99236). Those are distinct from what is described above.

All in all, don’t take my word for it. Here’s the link to the actual CMS bulletin:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6740.pdf.

It’s readable, too, which is nice.

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