Ob-Gyn Coding Alert

ER Consults:

Identifying Consultations Vs. Outpatient Visits

When an ob/gyn is called to see a patient in the emergency room (ER), a number of different scenarios and outcomes can take place. Although automatically coding the visit as an ER consult may seem pretty basic, there are several different elements to consider before identifying the visit as a consultation.

An emergency room consultation can be very confusing for people, says Thomas Kent, CMM, principal of Kent Medical Management in Dunkirk, Md. When a doctor sees a patient in the ER, many coders first reaction is to use the code for an emergency room visit (99281-99285, emergency department visit for the evaluation and management of a patient). But the rule to remember is that only the first doctor who sees the patient can use the ER code. So if the ob/gyn is called to the ER by another doctor who has already seen the patient, the ob/gyn cannot use the ER code to bill the encounter. If you remember this ground rule, says Kent, things are a little more clear when determining the proper code.

The flip side of this rule is when a patient calls into the ob/gyns office with a complaint. If the ob/gyn advises the patient to meet him or her at the emergency room, the patients first encounter would be with their ob/gyn and the appropriate level of ER code would apply. But, Melanie Witt, RN, CPC, MA, former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG), advises, The physician can choose to code either an ER visit or an outpatient visit in this case and should be aware that reporting a emergency room visit does not always result in a higher payment. This is because ER codes do not have a time component and all three of the key components of history, examination and medical decision-making must be met or exceeded.

Making Sure the Service Adds Up
to the Proper Code

This may mean that the physician will end up coding a lower level of ER visit. For instance, says Witt, lets say that the physician sees the patient in the ER for vaginal bleeding. The patient is his established patient and he has been treating her for this condition for two weeks. She is having particularly heavy bleeding so he tells her to meet him in the ER. He performs a detailed examination, documents an HPI (history of present illness but not a family, personal or social history), documents a pertinent review of systems and then decides to perform surgery (so that medical decision-making is moderate). With this scenario, the level of history will be only problem-focused, meaning that instead of being able to bill a level four ER visit (99284, detailed history, detailed exam, moderate medical decision-making), the service can now only be coded as a level one (99281, problem-focused history, problem-focused exam and straightforward medical decision-making) because all three key components were not met or exceeded.

Witt explains that if the physician elects to bill this visit as an established patient outpatient service, a level four visit would be reported. Under RBRVS, 99281 has an RVU of 0.55; 99284 has an RVU of 1.47.

Another point to remember is that if a patient reports to the emergency room and then is admitted to the obstetrics (ob) ward, at which point the obstetrician is called, the encounter is not considered an ER visit at all. So 9928199285 would not apply.

Three elements must be present for the encounter to be considered a consultation:

1. Provider requestthe input of the ob/gyn must have been requested by the ER doctor

2. Patient encounterthe ob/gyn must see the
patient and conduct an evaluation

3. Follow-up letterthe ob/gyn writes a letter, or in this case a note to the ER record detailing the encounter and his or her findings.

Documentation must show these three things to bill for a consult. Even if the ob/gyn admits the patient to the hospital, if the three elements are present, the visit can be billed as a consultation. The type of consultation code is determined by where the patient ends up at the end of the day.

If the patient is discharged from the emergency room and sent home, the applicable codes are 9924199245 (outpatient consultation for new or established patient).

If the patient is admitted to the hospital, the ob/gyn
can use the initial inpatient consultation codes
99251-99255) or the initial hospital care codes (99221-99223), but not both.

In determining whether to use initial inpatient consultation or initial hospital care codes, Kent says the choice is based on whether a procedure is performed. If the ob/gyn is simply admitting the patient for medical care with no surgical procedure, use the hospital admission codes, says Kent. If the patient is being admitted for an emergency procedure, such as a dilation and curettage, the initial inpatient consultation codes apply. If this is the case, says Kent, a -57 modifier (decision for surgery) should append the consultation code, accompanied by the procedure code. The rationale here, Kent explains, is that -57 works better on consultation codes than it does on admission codes. Technically, the -57 modifier is applicable to the admission codes, but my experience is that this modifier is less likely to get an initial denial when attached to the consultation code.

Include Details in the ER Notes

Kent explains that semantics often play a role in whether an ER encounter is considered a consultation or not. For example, an ER doctor sees a patient and determines that she needs to be seen by a gynecologist, says Kent. How this is phrased in the ER notes is particularly important. If the notes say that the emergency room doctor requested the gynecologists opinion or advice, then it is a consultation. But if the ER doctor hands the patient over to the gynecologist for care and essentially steps out of the picture, then it is not a consultation.

Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, a medical billing and coding consulting firm in Lakewood, N.J., expands on Kents point about wording. Basically, says Cobuzzi, it is harder to have an ER problem in gynecology than in other specialties. The ER doctor needs the opinion of the ob/gyn more so than if they were treating a fracture. They may have an orthopedist come in to set the fracture, but they dont need a second opinion to tell them its a fracture. Usually, the gynecologist is being called in for their opinion. The ER doctor will diagnose that the patient is hemorrhaging, but the gynecologist diagnoses the need for a total abdominal hysterectomy.

Cobuzzi advises that the way doctors present these findings in the records is important. If doctors fail to use the key terms that auditors are looking for, a consultation may appear as a transfer of care to the auditor.

Kent also explains that in ER consultations, the ob/gyns previous history with the patient is not relevant to coding. If the ob/gyn is asked for his or her opinion and advice, it is a consultation, he says. It does not matter whether you are treating an established patient.

Kent cautions not to overcode as a consultation unless the three key elements are present. Remember, he says, if you (the ob/gyn) see a patient and she is discharged, but you dont feel entirely comfortable using the consultation codes, code the encounter as an outpatient office visit (using 99212-99215, depending on the level of service).

This is the most conservative way to code, says Kent, and unfortunately also the least profitable. But Im always surprised that so many coders are not aware that they can bill outpatient codes even when the encounter takes place outside of the office. Part of the CPT definition for Office or Other Outpatient Services reads in the physicians office or in an outpatient or other ambulatory facility, so from a coding point of view, the ER can be considered an outpatient facility. Many consultations are miscoded because of this.