Part B Insider (Multispecialty) Coding Alert

Published on Wed Oct 05, 2005 PDF

Plus:  See what the crystal ball reveals about coding consults in 2006

Do you shudder at the site of a hospital E/M service? Our experts teach you how to overcome your most common claim mistakes and offer up tips to prepare you for changes coming down the line.

1. When should I report codes 99261-99263?

CPT 2006 will eliminate these often misused codes (99261-99263, Follow-up inpatient consultation for an established patient ...). Experts say you should report CPT 99231 -99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) for these follow-up consultations come January 1.

Good news: In 2005, subsequent care pays more than follow-up consults, says Melanie Witt, RN, CPC, MA, a coding expert based in Guadalupita, NM. Because you'll code follow-up consults as subsequent care in 2006, you should be paid at the higher subsequent care rate for follow-up services in the new year.

What to do: For now, keep a sharp eye on your claims to be sure you're using 99261-99263 correctly.

For services before Jan. 1, you should use 99261-99263 if your physician completes a consult, returns the information to the referring physician and the referring physician requests a subsequent consult. This may occur when the patient is not responding to treatment, explains Lori Hendrix, CPC, CPC-H, director of coding and compliance for MDeSolutions in Atlanta.

Example: A diabetic patient is admitted to the hospital with a fractured hip. The treating physician asks your physician in for a consult to prepare a sliding scale for her insulin. A few days later, the treating physician requests another consultation to adjust the scale. You report a follow-up consultation for this second visit, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

You may also report a follow-up consult when a physician begins a consult one day but is unable to complete it and must return at a later date, says Hendrix. Code the initial visit as an initial inpatient consult and the return visit as a follow-up consult.

Hidden trap: In this situation, only report one follow-up consult, advises Nancy Reading, RN, BS, of CedarEdge Medical, LLC, in Blanding, Utah.

2. What codes should I use for confirmatory consults in 2006?

Along with 99261-99263, CPT 2006 eliminates confirmatory consult codes 99271-99275 (Confirmatory consultation for a new or established patient ...).

If your physician provides a confirmatory consult (second opinion) service in 2006, you should report an inpatient or outpatient E/M code instead of a consultation code. Why: Patients--not providers--request confirmatory consultations, Witt explains.

Note: Confirmatory consults often involve face-to-face counseling, says Witt.

Benefit: If counseling or coordination of care dominates the visit in 2006, and you report an inpatient or outpatient E/M, you will be able to choose a higher-level code based on the amount of time.

Example: Your physician provides services that typically merit 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three components: an expanded problem focused interval history; an expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit).

Your physician documents a floor time of 40 minutes total. He documents that he counseled the patient for 25 minutes.

Because the physician spends more than 50 percent of his floor time on counseling or coordination of care, CPT guidelines say you may use time as the controlling factor when choosing your E/M code. In this case, that means you may report higher-level E/M 99233 (...Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit) and boost your RVUs.

3. Should I report 99221-99223 for hospital admissions?

Codes 99221-99223 (Initial hospital care, per day, the evaluation and management of a patient ...) are not admission codes. They represent initial hospital care that may or may not take place on the same day as admission, reports Cobuzzi. But only the admitting physician may report 99221-223.

Example: Your physician admits a patient to the hospital at 10 p.m. on Monday night. The physician does not complete E/M work until the following morning. You should report an initial hospital care code for your physician's services that morning.

4. May I code two initial inpatient consults for the same patient?

Depending on the circumstances, you may be able to report 99251-99255 (Initial inpatient consultation for a new or established patient ...) more than once for the same patient.

Key: In order for you to code two initial inpatient consults you must have a discharge and subsequent readmission between the two, stresses Cobuzzi.

Example: Your physician sees a patient for an initial inpatient consult that merits 99253 (... which requires these three 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 55 minutes at the bedside and on the patient's hospital floor or unit).

Five days later the patient is discharged but is admitted again for the same illness. Your physician may then perform another initial inpatient consultation if requested.

5. What documentation should I see before I code 99239?

Many physicians forget to document the time they spend on discharge and therefore miss the chance to report 99239 (Hospital discharge day management; more than 30 minutes), Cobuzzi says. This mistake costs you about $20 every time.

Remember: Codes 99238 (... 30 minutes or less) and 99239 are time-based codes, so it's vital that your physician document floor time, Hendrix notes.

What to look for: "These codes include final exam, writing prescriptions, discussing the hospital stay and patient instructions to all caregivers," notes Hendrix.

You may include coordinating care with departments or agencies, such as social services, adds Cobuzzi.

Bottom line: Choosing E/M codes based on descriptors can lead you astray. You need to understand the guidelines and exceptions--such as the 50 percent rule for counseling--to keep your claims error free. Pay attention to carrier guidelines and keep an eye out for more changes in 2006.