Selecting a Consultation Service Level?

Part 2

By G. John Verhovshek, MA, CPC

Part 1 of this feature (“Consult or Not? Here’s How to Know for Sure,” May 2009 Coding Edge) discussed how to differentiate a consultation service from other E/M services. This month, we conclude with an explanation of how to apply consultation codes in inpatient and outpatient settings.

In addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. Having confirmed that these standards were met and documented, and having established that the intent of the service was to allow the requesting physician to continue to treat the patient with the advice of the consulting physician, you can get down to the business of selecting the appropriate consultation code for the service provided.

We explained that in addition to the usual medical necessity requirements, any consultation service must include a reason, request, and response. After these standards are met and documented, and it is established that the service’s intent was to allow the requesting physician to continue treating the patient with the help of the consulting physician’s advice, you can get down to the business of selecting the appropriate consultation code for the service provided.

This month, we’ll conclude this two-part consultation series with an explanation of how to apply consultation codes in the inpatient and outpatient settings.

Consultation codes do not distinguish between new and established patients. A physician may report a consultation for his or her own patient, as long as all the consultation requirements are met. CPT® does, however, assign unique codes for outpatient and inpatient services.

Select outpatient consultation codes 99241-99245 for “consultations provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care or emergency department,” according to CPT® instructions.

To report physician consultations “provided to hospital inpatients, residents of nursing facilities or patients in a partial hospital setting,” select from the inpatient consultation codes (99251-99255), CPT® continues.

Three of Three Required to Support Service Level

To report a given service level, coding guidelines require the consulting physician to meet all three key components: history, exam, and medical decision making (MDM). For example, to report a level III outpatient consult (99243 Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family), the physician must document, at minimum, a detailed history, a detailed examination, and MDM of low complexity. If any one of the three components falls below the minimum requirement, you may not report 99243.

In practice, the least or lowest of the three components will always dictate the appropriate service level when reporting a consultation. For example, if the physician documents an outpatient consultation with a comprehensive history, a comprehensive exam, and straightforward MDM, the code selection will default to 99252 Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit. Although the history and exam meet the requirements of a level IV visit (99254 Inpatient consultation for a new or established patient, which requires three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit), the MDM component supports only a level II service.

Keep in mind: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted,” according to the Medicare Claims Processing Manual, chapter 12, section 30.6.1.A (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf).

Time May Factor Into Code Selection

If more than 50 percent of the total, documented time dedicated to a verifiable consultation service is spent in patient counseling or physician care coordination, you may determine an appropriate consultation service level using time (rather than history, exam, and MDM) as the key component. Each consultation code (inpatient and outpatient) includes a reference time to guide you when using time as the key component.

For instance, CPT® specifies for a level II outpatient service (99242 Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient(s) and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family), “Physicians typically spend 30 minutes face-to-face with the patient and/or family.” For a typical 30-minute visit, the physician would have to document at least 16 minutes of face-to-face counseling or coordination of care to report 99242 using time as the key component.

In the inpatient setting, physician time includes time spent at the patient’s bedside (face-to-face time), as well as time on the patient’s hospital floor or unit.

Multiple Outpatient Consults Are Possible

A physician may report more than one outpatient consult for the same patient. The subsequent visit, however, must meet all the consultation service criteria to bill it as such, according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.C. Subsequent visits not meeting the consultation service requirements should be reported using the appropriate inpatient or established outpatient E/M service code. The Claims Processing Manual reiterates, “If the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.”

For example, a primary care physician (PCP) examines an established patient and diagnoses a breast mass. The PCP sends the patient to a general surgeon for advice. The general surgeon examines the patient and recommends a breast biopsy. The surgeon schedules the biopsy and sends a written report of his recommendations to the requesting physician. The general surgeon subsequently performs the biopsy, and continues to see the patient on a yearly basis for follow-up. Following the advice and intervention by the surgeon, the PCP resumes the patient’s general medical care.

In this case, the initial visit with the general surgeon meets all the requirements of an outpatient consultation, and may be reported as such (eg, 99242). Subsequent visits provided by the surgeon, however, should be billed as an established patient visit in the office or other outpatient setting (99211-99215), as appropriate.

In a second example, the patient from the previous example visits her PCP some months later with a new complaint of lower abdominal pain. The PCP requests a consult from the same general surgeon. In this case, as long as the visit for abdominal pain meets all the consultation requirements, the general surgeon may report another consultation service, as appropriate to the documented service level provided.

Avoid Shared Visits When Reporting Consultations

A non-physician practitioner (NPP) may perform a consultation service within the scope of practice and licensure requirements for NPPs in the state where he or she practices, and when the requirements for physician collaboration and physician supervision are met, according to the Medicare Claims Processing Manual, chapter 12, section 30.6.10.A. State and payer guidelines vary, however, so research your particular state and payer requirements before reporting as a consultation any service provided by an NPP.

The Claims Processing Manual states flatly that a consultation “will not be performed as a split/shared E/M visit.”

A shared visit describes an E/M service during which a physician and an NPP each see a patient for a portion of the same visit. For example, if the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service, according to the Claims Processing Manual, section 30.6.1.B. “In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the ‘incident to’ requirements are met, the physician reports the service. If the ‘incident to’ requirements are not met, the service must be reported using the NPP’s UPIN/PIN,” the Manual continues.

Report One Inpatient Consult per Stay

A physician may report only a single inpatient consult per inpatient stay. CPT® instructions state, “Only one consultation should be reported by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes 99231-99233 or Subsequent Nursing Facility Care codes 99307-99310,” depending on the setting.

For example, a hospital inpatient experiences a new onset of atrial fibrillation. The managing physician requests a consultation from a cardiologist for her advice on the patient’s care and management. The cardiologist examines the patient, schedules a cardiac catheterization and other diagnostic tests, and sends a written report to the requesting physician. Following the advice and intervention by the cardiologist, the managing physician resumes the patient’s general medical care. In this case, the cardiologist may report an inpatient consultation for her services at the level supported by documentation. If the cardiologist follows up with the patient during the same inpatient stay; however, she must report the visit(s) as subsequent inpatient care (99231-99233), as appropriate to the documented service level.

If the same physician provides a legitimate consult service during a different inpatient stay for the same patient (whether for the same or a different problem), the physician may report another inpatient consult code, as appropriate to the documented service level.

For instance, the patient in the previous example has been discharged, only to be re-admitted several weeks later. If the same cardiologist who reported the previous consultation meets the requirements for a consultation service during the subsequent stay, she once again may report an inpatient consultation code (99251-99255) for her services.

For an excellent summary of Medicare rules regarding consultations, see MLN Matters article MM4215 on the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/mm4215.pdf.

Coding Edge Sidebar

CMS Defines Pre- and Postoperative Consultations Rules

The rules for reporting a consultation for preoperative clearance, as well as for postoperative care by the physician who provided a preoperative clearance consultation, are spelled out in the Medicare Claims Processing Manual, chapter 12, sections 30.6.10.G and 30.6.10.H, respectively.

Specifically, preoperative consultations are payable for new or established patients when performed by a physician or qualified NPP at the surgeon’s request as long as all of the requirements of a consultation are met and the service is medically necessary and not routine screening. Typically, a V code (for example, V72.81 Preoperative examination, cardiovascular) is linked to the appropriate consultation code to describe the service.

A physician should not report a post-operative consultation if, following completion of a preoperative consultation (whether in the office or hospital), the consulting physician assumes responsibility for the management of a portion or the entire patient’s condition(s) during the postoperative period. Rather, in an inpatient setting, the physician would report the appropriate Subsequent Hospital Care (99231-99233) or Subsequent Nursing Facility Care (99307-99310) code(s), depending on the setting. In the outpatient setting, the appropriate established patient visit codes (99211-99215) should be used during the postoperative period.

A physician (primary care or specialist) or qualified NPP “who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consultation,” according to the Claims Processing Manual.

G. John Verhovshek, MA, CPC, is AAPC’s director of clinical coding communications.

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