The Top 5 Things You Need to Know About Inpatient Consultations

Editor’s note: In the calendar year (CY) 2010 MPFS final rule with comment period (CMS-1413- FC), the Centers for Medicare & Medicaid Services (CMS) eliminated the payment of all CPT® consultation codes (inpatient and office/outpatient codes) for various places of service except for telehealth consultation HCPCS Level II G-codes.

By Jennifer Swindle, RHIT, CCS-P, CPC-EMS, CCP

Consultations in all settings are a source of frustration and confusion for many medical professionals. Although the CMS Manual System, Pub 100-04 Medicare Claims Processing Transmittal 788, clarified how to report consultation codes, it is still a topic of discussion and sometimes dissention between coding professionals and healthcare providers.

Evaluation and Management – CEMC

Often, when a patient is referred from one physician to another, it is instinctively seen as a consultation by the physician receiving the patient; however, this may not be true. A consultation is different from a visit as there is a request or opinion from another physician, appropriate source or qualified non-physician provider (NPP), but there is not an already predetermined referral for treatment. If there is a known transfer of care of a specified problem from the referring provider to the specialist, a consultation code is not supported.

Inpatient consultations ultimately have the same definition as an outpatient or office consultation. The driving factor of the correct CPT® code is the intent of the encounter. The intent of a consultation is for another source to request the physician or NPP’s advice, opinion, guidance, input, or help in making recommendations for evaluation or treatment of a patient as their expertise in a medical area is beyond that of the requestor.

What are the things that you need to know in an inpatient setting?

  1.  There must be a request from another health care provider documented in the common medical record which indicates the consultant is expected to provide advice and/or opinion. The request must include the need for consultation. If the care of a specified problem is being transferred from one physician to another prior to the service, it does not support a consultation, but instead, should be reported as a subsequent hospital visit.
  2. The consultant must document the findings, including advice or opinion in the common medical record, so it is readily accessible to the provider requesting the service. The consultant should report this initial service as an initial inpatient consultation code (99251-99255), with the level determined by the medical necessity of the visit and supported by the documentation guidelines.
  3. The initial provider requesting the service will use the consultant’s findings in the ongoing care of the patient. If, after receiving the consultant’s findings, the initial provider transfers the care of the problem to the consultant, this is still use of the advice or opinion. A consultation code for the initial service is still appropriate, as the transfer occurred after the initial service.
  4. Only one initial inpatient consultation can be reported during a single episode of care. If the consultant is called back for a follow-up service during the same hospitalization or the consultant continues to follow a patient for an identified problem, a consultation code is not appropriate and the follow-up service or subsequent visit should be reported as a subsequent hospital visit (99231-99233).
  5. A consultant may initiate diagnostic and/or therapeutic services at the time of the initial service if they are medically necessary and does not limit the appropriateness of billing a consultation code. A consultation may be reported if the referring physician does not transfer the responsibility of the patient’s care of the specified problem to the receiving physician until after the consultation is complete.

The Office of Inspector General (OIG) often has consultation codes in its Work Plan, due to the financial impact and error rate of consultation services. Medicare paid $4.1 billion for consultations in 2004 and the OIG has estimated that three out of every four consultations either don’t support a consultation or don’t support the level of consultation reported.

Documentation guidelines for a consultation service require that all three key components (history, examination, and medical decision-making) be met to support the correct level of consultation. Note: the only variant between a level four and a level five consultation is the medical decision-making component. A level four requires moderate complexity medical decision-making and a level five requires high complexity medical decision-making, but both levels require a comprehensive history and a comprehensive physical examination. (See table below):

Initial Inpatient Consultations (3 of 3)

History

 

Problem
Focused 
Expanded
Problem Focused 
Detailed

 

Comprehensive

 

Comprehensive

 

Exam

 

Problem
Focused 
Expanded
Problem Focused 
Detailed

 

Comprehensive

 

Comprehensive

 

Medical
Decision Making 
Straightforward

 

Straightforward

 

Low
Complexity 
Moderate
Complexity 
High
Complexity 
Consultation

 

99251

 

99252

 

99253

 

99254

 

99255

 

 

If a physician documents an expanded problem-focused history, comprehensive examination and moderate complexity medical decision-making, the correct code is 99252, as that is the only level where all key criteria are met.

There are instances when the level of consultation is determined based on time spent with the patient (if more than 50 percent of the time is spent in counseling or coordination of care), but the practitioner must clearly document the time spent in consultation and the fact that more than 50 percent of the time was spent in counseling or coordination of care. If time is the component used to bill a consultation, the criteria for consultation, including the documented request and reason for the request, must still be met.

Consultations are a valid and appropriate service provided in all medical care settings. It is imperative that coding professionals, physicians and non-physician providers, are well aware and compliant with the definitions and requirements of a consultative service and report them appropriately.

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