Wiki Billing Hospital Consults

[debneas]

One of our providers (we are a specialist group) did a consultation in the hospital. The patient is on Medicare. Since you can't bill consultations, what CPT code should we use? I know to change the place of service.

 

[mitchellde]

You use initial hospital visit codes. No modifier.

 

[debneas]

99223 or 99233? The provider wants to charge a level 3

 

[mitchellde]

The criteria between the 99223 and the 99233 is different. For a consult in the inpatient setting you use the 99221-99223. The level you chose will depend on what is documented.

 

[debneas]

We usually use 99221-99223 for the initial consultation, but the CPT book says "the following codes are used to report the first hospital inpatient encounter with the patient BY THE ADMITTING PHYSICIAN".

We did not admit the patient that's why that code set is throwing me off.

 

[avon4117]

Did the Dr consult the pt in an inpatient setting or while the pt was in the ER/OBS?

 

[debneas]

inpatient setting

 

[mitchellde]

We usually use 99221-99223 for the initial consultation, but the CPT book says "the following codes are used to report the first hospital inpatient encounter with the patient BY THE ADMITTING PHYSICIAN".

We did not admit the patient that's why that code set is throwing me off.

I know the CPT book indicates that but it is just an instructional note not a definition. The codes are defined as initial inpatient encounter codes. When you are the consulting provider, seeing a patient for the first time, with a new issue, then this is your initial encounter in the inpatient setting. Notice it is either new or established. Ideally you would use a consult code but for Medicare and other payers these are not recognized codes.

 

[avon4117]

then the 99221-99223 would be appropriate according to the AMA CPT 2016

 

[mitchellde]

Yes they are the correct choice.

 

[debneas]

That's what I thought and was second guessing myself.
Thank you!

 

[wbradhoward]

MCR consultations changed to new/established encounters

Question: When a patient is seen in consultation by a specialty provider, and the patient has Medicare, I know that you have to choose between new and established visit codes based on patient status (inpt, outpt, obs).
My question is if the patient is known to the consulting service (within last 3 years), will you always change to the established patient codes? I was under the impression that you could still conceivably bill a consultation for a known patient, but when changing the consult because of MCR status will you always have to pick the established patient code in this case?
Any help, as always, is appreciated!

 

[mitchellde]

ye sit will be an established patient since the patient meets that criteria.

 

[astrom01]

Hospital Consultations

If a PA does a hospital consultation de we have to bill for that or can we have the patient just come to the office and we bill a new patient visit then?