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Conquering Consults

Kim Reid, CPC, CPC-I, , , ,CEMC

Objectives

Clearing p cons lt conf sion• Clearing up consult confusion

• Understanding the consult requirements

• How do we code/document now that Medicare no longer recognizes

consultsconsults

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What is a Consult?

• A request from one Health Care Provider t th f th i d i d i ito another for their advice and opinion regarding a patient’s condition

• If the request is to a specialist, wouldn’t EVERY initial visit be a consult?

• What is the difference between a• What is the difference between a

new patient visit and a consult?

When to Bill Consults

• There must be a specific request for a lt f id t thconsult from one provider to another

– Can be verbal but should be documented where the request came from

– Confusion begins when the

documentation is not clear as to

what is being requested

– Can co-management be considered

a “standing request” for a consult?

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New Patient or Consult

• If the service was not requested by th id it t b bill danother provider, it can not be billed as a

consult– Patient heard the provider was the best in the

field so they made an appointment on

their own to be assessed

– Second opinion

– Follow-up visits

New Patient or Consult

• Consults can be billed even if the patient is t “ ” t th tinot “new” to the practice

– Consult may be billed whenever there is a request for advice and opinion

• Pre-operative exams

• Patient develops a new problem

• Same problem progresses beyond

what was anticipated

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Initiation of treatment

• What if treatment is initiated?– Based on the provider’s assessment, they are

able to initiate treatment and still bill the service as a consult

– Not considered a “transfer of care” • Requires a written document between

two providers that states a transfer of

care is taking place

Medicare and Consults

• As of January 1, 2010 Medicare no longer recognizes consultsrecognizes consults

• An effort to “level the playing field”– Shortage of Primary Care providers– Eliminated consults and increased

reimbursement for other E/M services th b dacross the board

– All providers will be reimbursed at the same rate

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Alternative Coding

• Outpatient consults for Medicare are now bill d t bli h d ffi thbilled as new or established office or other outpatient services– These are a one-to-one match in the

documentation guidelines

– Advice and opinion regarding a new

problem on a patient seen less than

3 years ago

Alternative Coding

• Consults while the patient is in observation t tstatus– Since the patient is not admitted, they are

considered outpatient so the same rules apply as “office or other outpatient services”

• 99201 - 99205

• 99212 - 99215

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Alternative Coding

• Emergency department visits– Patients seen in the ER should be coded with

the appropriate ER code (99281 – 99285)• If assessed by an ER physician and then a

specialist is called in to see the patient as

well, both providers will bill the

appropriate ER codeappropriate ER code

• If patient is admitted by the specialist,

the specialist will bill the appropriate

initial hospital visit code with an AI

modifier

Alternative Coding

• Initial Hospital Visits– The attending of record uses Initial Hospital

Visit codes (99221 – 99223) with an AI (not number one, but letter I – eye)

– These codes can be used by multiple providers throughout the patient’s

hospital stay • Except when providers are in the

same group, same specialty

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Alternative Coding

• The documentation requirements for i ti t i NOT tinpatient services are NOT a one-to-one match to the consult codes

• Can lead to reduced payment due to insufficient documentation

• Only three levels for Initial Hospital• Only three levels for Initial Hospital

Visit as opposed to five levels

for consults

Alternative Coding

• Code 99222 is a one to one match with d 99254code 99254

• Code 99223 is a one to one match with code 99255

• Code 99221 does NOT have a one

to one matchto one match

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Alternative Coding

• Requirements for 99221 (3 of 3 key t )components)

– Detailed History

– Detailed Exam

– Straightforward MDM

• Best match = 99242Best match 99242– Expanded Problem Focused History

– Expanded Problem Focused Exam

– Straightforward MDM

Alternative Coding

• What is the correct code to bill when the d t ti d t t thdocumentation does not meet the requirements for the lowest level of Initial Hospital Visit?

• Options:– Unlisted E/M codeUnlisted E/M code

– Subsequent Hospital Visit

– Just bill the lowest level because

there is not another option

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Alternative Coding

• At the 2010 AMA CPT Symposium CMS ifi ll t t d th t it ld NOT bspecifically stated that it would NOT be

appropriate to bill an unlisted E/M service in this case

• We want to code for the work that

was performed so we would notwas performed so we would not

bill the service anyway

• Maybe we should not bill anything

at all…

Alternative Coding

• We would be required to bill for a S b t H it l Vi it h thSubsequent Hospital Visit when the documentation does not meet the requirements for a higher level code

• Depending on the documentation,

either a 99231 or 99232 would beeither a 99231 or 99232 would be

appropriate

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Alternative Coding

• Requirements for 99231– Problem Focused History

– Problem Focused Exam

– Straightforward MDM

• Requirements for 99232Expanded PF History– Expanded PF History

– Expanded PF Exam

– Moderate MDM

Solutions

• What is the solution to all this confusion?– EDUCATION

– EDUCATION

– EDUCATION

• If the providers are not interested,

keep track of the amount of timeskeep track of the amount of times

you have to reduce their coding

due to insufficient documentation

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Conclusion

• It is a good idea to get the providers to d t d th d t tiunderstand the documentation

requirements for all the levels of service

• Provider education is the key to understanding alternative consult

coding optionscoding options

• It is unknown if other payers will

follow CMS in the elimination of

consult services in the future

QuestionsDo we have all our ducks in a row?