Orthopedic Coding Alert

Although weve discussed coding for consults in the Emergency Department in previous issues, orthopedic consults continues to be a hot topic, both among orthopedists (who want to optimize reimbursement) as well as the Office of Inspector General (who has overcoding for this service on its hit list for 1999). Now, readers have asked us to determine when to code for consult or transfers of care when patients are admitted for fractures.

For example, a reader submitted this question: What is the proper E/M code to use when an orthopedist is asked to see a patient admitted with syncope who also sustained a wrist fracture during an episode? The orthopedist is first consulted for treatment on the care of the fracture but then assumed all care for that diagnosis.
Whether you code this type of service as a consult or transfer of care depends on whether you follow the CPT guidelines Section 15506 of the Medicare Carriers Manual (MCM).

They differ in that they do not agree on when a receiving physician can appropriately charge for an inpatient consult. For example, the CPT says the initial encounter can be billed as a consult even after transfer of care in the hospital setting:

If after a consultation is complete, the physician assumes responsibility for management of a portion or all of the patients condition, then he or she should use the appropriate inpatient hospital consultation code for the initial encounter and then subsequent hospital care codes (not follow-up codes).

Some sources, referring to the CPT guidelines, say that all initial encounters can be billed as inpatient consultations (99251 to 99255) with follow-up care billed as subsequent care (9923 to 99233). For example, Dawn Carpenter, CPC, billing manager at Ortho Associates of Grand Rapids, MI, says she probably would have used an inpatient consult code for the service in the syncope scenario. Our practice uses consultations primarily as we evaluate our patients and then make the decision to treat. In that case, we would bill the consultation with modifier -57 and then the fracture care service, she says.

However, a more conservative approach is typical of Todd Thomas, CPC, CCS-P, president of the Oklahoma Chapter of the American Academy of Procedural Coders. Thomas, who points out the definition of consults in the MCM, sees similar cases as a transfer of care, not a consult.

Most of the time when an orthopedist is called about an injury, he or she is not being asked by the requesting physician to provide opinions or advice on how that physician should care for the patient, but to actually take care of a fracture or dislocation, he explains. Therefore, even the initial encounter should not be billed as a consult.

Specialists often disagree because they cite the CPT guidelines, along with the MCMs rule, that a consultant may initiate diagnostic and/or therapeutic treatment.

MCM, Section A 15506, does say that a consultant may initiate diagnostic and/or therapeutic services. However, it is also clear that the Health Care Financing Administrations (HCFA) definition of transfer of care hinges on the intent of the requesting physician: If he or she is asking for advice, its a consult. If he or she does not have the skills to fix the problem and wants the specialist to do so, its transfer of care.

From Section A: However, when the referring
physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally (i.e., following the request to evaluate and treat), the receiving physician should not continue to bill a consultation visit. He or she would bill a subsequent hospital care code in the hospital setting or appropriate established patient code in the office setting.

Section B, Consultation Followed By Treatment, continues to emphasize that HCFA will pay for a consultation if the referring physician does not transfer the responsibility for the patients care to the receiving physician until after the consultation is finished.

In light of the Medicares assaults on overcoding of consults, many coders are leaning toward defining the word consult as a request for an opinion onlydespite the verbiage in the CPT.

Automatically billing a consult for the initial visit could get you in trouble with HCFA, points out Quin Buechner, MS, CPC, consultant for Webster, Rogers, Grady, Benson, King, Skipper, in Florence, SC.

So, if you decide to code strictly by Medicare guidelines, do not use a consult code for the fracture care in the syncope case. Instead, use the appropriate level of the subsequent hospital care codes (99231-99233).

Note: You cant code the encounter as initial hospital care (99221-99223) because only the admitting physician can use this code.

The bottom line is: Is the orthopedist being asked for an opinion, or is he being asked to fix the problem? asks Susan Stradley CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC.

So when can an orthopedist appropriately charge for inpatient consults, according to the MCM?

Tina Rud, surgical specialist at Twin Cities Orthopedics in Cambridge, MN, provides a scenario in which it is correct to bill a consult:

A 79-year-old woman who fell and hit her shoulder was first brought to the ED and then admitted. We were asked to see her for evaluation of her shoulder. The diagnosis was a fractured surgical neck, left humerus. The patient will be treated with a sling for approximately three weeks and then started on an exercise program.

Because the requesting physician was not sure if something needed fixing, he asked for the orthopedists opinion: Do you think a surgical procedure needs to be done? she says. This service should most definitely be billed as a consult.

Whether to code as a consult or subsequent inpatient visit, depends a lot on the injury itself, she explains.

For example, in another case provided by Rud, a
56-year-old woman was hit by a car, brought to the emergency room, and then admitted. Because the CT showed a pelvic fracture, the orthopedist was called. He determined the fracture was satisfactory for weight bearing and would not require any internal fixation. He recommends early mobilization to preserve ambulatory function.

This service should be billed as a consult because the requesting physician was in essence saying, Look at this pelvic fracture and tell me how to proceed with care, she explains. That is a request for advice or an opinion. That is not a request to treat or transfer of care.

For example, suppose in the above case the requesting physician had identified a totally displaced hip fracture that needed internal fixation. You cant bill an E/M code because the fracture repair has been identified and would never heal without fixation, i.e., without the skills and expertise of the orthopedist, she says. One of the litmus tests for consults is to ask yourself: Is the treatment beyond the skill of the requesting physician to fix?

If so, you cant safely bill a consult, at least according to Medicare.