Hospitalist Consults

Consult Your Hospital’s Policy

By Pam Brooks, CPC

An increasing number of hospitals nationwide have discovered the benefits of implementing a hospitalist program. Hospitalists provide excellent inpatient and observation care as in-house internal medicine specialists available at a moment’s notice, and many specialists and surgeons have benefited from their presence on campus. Hospitalists can provide the primary care needs of an inpatient following surgery, in conjunction with other specialty care, and when the patient is from another geographic location.

A hospitalist is a physician who specializes in the care of hospital patients, according to the CMS document What is a Hospitalist? “For older patients, a hospitalist will most often be an internal medicine doctor or a family doctor,” the document says. “A hospitalist might be a specialist in pulmonary (lung), cardiology (heart), or other diseases.”

So how do you code and bill for the hospitalist’s services? There are as many scenarios as there are patients, and there is not one precise answer.

Look for Three Rs, Physician Intent

Consultations seem to pose the biggest problem within the hospitalist programs nationwide. Although the three “Rs” are generally met (e.g., request for opinion/advice, rendering of an opinion by the consultant, and response to the requesting provider), the savvy coder must also determine the intent of the visit. A transfer of care does not support a consultation visit.

For example, orthopedic surgeon Dr. Cutter has performed a total knee replacement on a patient with Type 2 diabetes who is also insulin dependent. Although the surgery was successful, the patient’s diabetes requires post-surgical monitoring that the surgeon would prefer not to do. She has decided that Dr. Inn-House, the hospitalist, should co-manage this patient by focusing on the diabetes care. Although she asks Dr. Inn-House to “consult,” (and here’s where it can get tricky), her initial intent is to transfer the care of the patient to the hospitalist program.

Dr. Inn-House’s first E/M visit with the patient would not be a consultation, but a subsequent inpatient visit, billed with the ICD-9-CM code that reflects the patient’s current diabetes mellitus (DM) status, along with any other co-morbidities. So how can the hospitalist provide consultation visits within the hospital setting? Only if the requesting physician responds appropriately as demonstrated below:

Let’s say that Dr. Cutter asks for Dr. Inn-House’s opinion regarding this same patient. Once Dr. Inn- House has provided his opinion regarding the DM care, Dr. Cutter can then document, “Thanks very much, Dr. Inn-House. Your input is very helpful, and I now know what course of action I can take regarding this patient.” Dr. Cutter can then decide to manage the DM herself, or send the patient’s care back to Dr. Inn-House for the remainder of the hospitalization. Dr. Inn-House bills a consultation, with further visits to this patient being subsequent inpatient charges. This back-and-forth is what sets the consultation apart from the subsequent visit, and clear documentation within the patient chart must be present in order to support the intent of the visits. Requests for impatient consults must be documented in the shared medical record per CMS.

In another scenario, Dr. Inn-House has been called down to the emergency department (ED) by Dr. Crisis to see if a patient with chest pain and syncope needs to be admitted. Is this a consultation? Maybe, say CMS and the CPT® codebook, depending on several factors. If a written request for the consult is in place, the opinion is rendered, and the response to Dr. Crisis is provided, then an outpatient consultation might be appropriate, particularly if the patient does not require admission to the facility. However, if the patient’s status were such that admission is appropriate, Dr. Crisis would then transfer care of the patient over to the hospitalist program. At this point, an initial hospital visit should be billed in lieu of the consultation.

Another consideration when determining whether a consultation would be appropriate is the institution’s written policies regarding patient care plans, pathways and protocols. Some hospitals have “standing orders” that mandate that all post-surgical patients over the age of 50 must be co-managed by a hospitalist. While this is excellent patient care, this facility mandate would override any request provided by a specialist to initiate a consultation by the hospitalist. Hospital policy cannot substitute as a request for a consultation. Each patient’s condition should be independently considered to determine whether a valid request for a consultation was made. It is inappropriate to provide a blanket consult request based on hospital mandate and not individual patient need.

While the hospitalist program is a model for excellent patient care, the coding issues that arise have brought new challenges to the professional coding world. Careful consideration of CPT® codebook rules, CMS guidelines, local medical review policies and hospital rules will allow the coder to make ethical decisions regarding the appropriate coding and billing of any visits that have been provided. Proper documentation is always key, and establishing a good working relationship with the facility’s hospitalist team will help ensure that clear-cut policies and guidelines are followed and implemented.

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