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Coding Consult: When a visit is actually a consult


You could be losing income if you think only specialists can be consultants. But make sure you follow the coding rules.


Coding Consult

When a visit is actually a consult

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Choose article section...When a visit is actually a consult Play by Medicare's rules Consultation codes at a glance

You could be losing income if you think only specialists can be consultants. But make sure you follow the coding rules.

Fred Chafin, CPC

How much money are you missing by not billing for consultations? Maybe plenty. Consultation revenue is most important to specialists, but primary care physicians should be generating some, too. And reimbursement for consults can be much higher than for inpatient or office visits.

Officially, a consultation is a request for your opinion or advice from another licensed provider or other appropriate source (your county health department, for example). The request must be in writing for inpatient consults, and "medical necessity" must be demonstrated. The consulting physician must prepare and submit a report of his findings and recommendations, which will then go into the patient's record. Copies of your examination notes do not meet this requirement.

There are three types of consultation: initial inpatient consultation (new or established patient), follow-up inpatient consultation (established patient), and office or other outpatient consultation (new or established patient). Let's look at a couple of situations that will allow you to bill for a consultation.

Scenario 1: You are considered an expert in diagnosing and treating hypertension. A surgeon who has admitted a patient asks you to evaluate him and render your opinion on his ability to tolerate the proposed procedure.

You do a comprehensive history and examination and provide a written report of your findings and recommendations to the surgeon. Medical decision-making is moderate, so you can bill a 99254 consult.

I've seen doctors bill this kind of service as an inpatient visit, thus forfeiting the higher-paying, legitimate claim for a consult.

Scenario 2: A surgeon performs a procedure on an established patient from your practice and asks you to conduct a postoperative evaluation. This patient has accelerated hypertension and diabetes. You perform and document a comprehensive examination and history.

Since the patient has one or more chronic conditions with severe exacerbation, the medical decision-making is of high complexity. Based upon these criteria, you can bill a 99255 consult.

In your written report to the surgeon, you'll need to distinguish this service from your routine management of this patient's diabetes.

Scenario 3: A surgeon asks you to see a patient he recently operated on. You report your findings and recommendations. The surgeon says, "I'll implement your recommended treatment, but I would like you to re-evaluate the patient in a couple of days to see whether the treatment is working."

You examine the patient in the hospital three days later and find her condition is worsening. You take an interval history, examine her, and decide that not only is the initial problem worsening, but the patient has now developed sepsis.

You spend 30 minutes stabilizing the patient and developing a new treatment plan. When you present your follow-up consult report to the surgeon, he asks you to take over care of the sepsis.

In this case, you can bill a follow-up inpatient consultation (99263). The use of this code indicates that the patient is unstable and has developed a significant new problem or complication that required two of the three following key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making.

Now, say you visit this same patient in the hospital the following day and find she has improved some but is still unstable. You order additional lab work, change the medications, and perform a detailed examination.

In this scenario, you can't bill a consultation. Once you've taken over treatment, you must bill for a follow-up visit. Code the visit as a 99233 (subsequent hospital care, level 3), because you have a patient who is unstable and you performed a detailed examination.

Play by Medicare's rules

One of the biggest problems with consultations is that many of the physicians who ask you to consult on a case remain unaware of the rules. Consider developing a simple form of instructions you can fax to these physicians. Here are important rules to pass along and to be aware of yourself:

One of the most important is that the Centers for Medicare & Medicaid Services (formerly HCFA) states that a consult for an inpatient must include a written request by another doctor. Say you meet a surgeon while making rounds, and he says, "While you're on the floor, would you look at Ms. X in room 505? She's a patient of yours, and I'm contemplating performing a bladder suspension. But since she's diabetic, I would like your opinion as to whether she's a candidate for this surgery."

You must ask the surgeon to write the request for the consult in the patient's chart. Otherwise, you can't bill for a consultation.

Outpatient consults don't require a written request because the chart isn't shared, as it is for inpatient services. But it's a good habit to note who requested the consult and when. You might want to ask for a written request anyway, especially if you don't know the requesting physician and need to provide his name and UPIN number on the insurance claim form. Ask the doctor to provide this request along with pertinent labs and tests.

With the right training, your receptionist should be able to spot appointments that are actually consults. All she has to do is query new patients who call for an appointment. Often these patients have been directed to see a specific physician for evaluation, but they don't tell that to his staff.

A second rule: "Medical necessity" must be demonstrated to justify the consult. So just because a doctor has requested a consult, your examination won't necessarily qualify as a consult. Say you meet a surgeon in the hospital hall, and he says, "I've just performed a bladder neck suspension on Ms. X, but I need you to consult on her case. As you know, her diabetes can easily get out of control, so I would appreciate your managing it."

What should you bill?

Most likely, you can justify billing a 99232, but not a consult. You were asked to manage this patient's diabetes, not render an opinion or advise the requesting physician. A consult is not a request to take over care of a disease or illness.

The fact that the surgeon said "consult" doesn't make your service a legitimate consult. He was simply asking you to take over management of the patient's diabetes. In this case, medical necessity for a consult wasn't demonstrated.

There are other rules. I was asked recently to conduct chart audits on a newly acquired nephrology practice. The audit included inpatient consultations in which the consulting physicians filled out a hospital-provided form titled "Consultant's opinion or advice." The consultants were doing just as the form says, writing their opinion and advice. But they failed to consider CMS guidelines requiring documented history, examination, and medical decision-making.

If subjected to a Medicare audit, these claims would be denied, even though the doctors deserved to be paid for consultations. So make sure you document correctly. And, as always, make sure your writing is legible.


Consultation codes at a glance

History and examination
Medical decision-making
Expanded problem-focused
Low complexity
Moderate complexity
High complexity
Expanded problem-focused
Low complexity
Low complexity
High complexity
Straightforward or low complexity
Expanded problem-focused
Moderate complexity
High complexity


The author, a certified professional coder, is a consultant and seminar leader for McVey Associates (mcveyseminars.com), an insurance reimbursement consulting company in Novato, CA. This department answers common coding questions. Since coding rules frequently change and are subject to interpretation by insurance carriers, decisions should be made in light of individual circumstances, local conditions, payer policies, contracts, and new or pending governmental policies. We welcome your questions for future columns. Please submit them to mecode@medec.com. Sorry, but we're not able to answer readers individually.


Fred Chafin. Coding Consult: When a visit is actually a consult.

Medical Economics


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