Billing initial inpatient admissions that were originally consults

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Chicago, IL
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Scenario:

Pediatric surgery physician is consulted to the ED and determines that the patient will be admitted to the hospital as an inpatient and submits an order for admission.

Question:

If this 'consult' note by the pediatric surgery physician does not meet the detailed/comprehensive, 3 out of 3 guidelines that initial inpatient 99231-99233 require, would you bill this as a consult (since it originated as a consult from the ED provider), or, a subsequent visit? If you can provide me documents I would greatly appreciate it.

I do have documents from the AMA that state, "if the level of history and PE performed and documented is expanded or problem focused, initial inpatient hospital care must be reported using subsequent hospital visit codes 99231-99233 because the required key components for code 99221 (ie, at least a detailed history and detailed examination) have not been met." The problem I have is that I do not have specific guidelines on consults turning to initial care.......which is basically every time my physicians see patients (patient always enters to ED and pediatric surgery is consulted).

Thanks!
 
Messages
811
Best answers
0
Scenario:

Pediatric surgery physician is consulted to the ED and determines that the patient will be admitted to the hospital as an inpatient and submits an order for admission.

Question:

If this 'consult' note by the pediatric surgery physician does not meet the detailed/comprehensive, 3 out of 3 guidelines that initial inpatient 99231-99233 require, would you bill this as a consult (since it originated as a consult from the ED provider), or, a subsequent visit? If you can provide me documents I would greatly appreciate it.

I do have documents from the AMA that state, "if the level of history and PE performed and documented is expanded or problem focused, initial inpatient hospital care must be reported using subsequent hospital visit codes 99231-99233 because the required key components for code 99221 (ie, at least a detailed history and detailed examination) have not been met." The problem I have is that I do not have specific guidelines on consults turning to initial care.......which is basically every time my physicians see patients (patient always enters to ED and pediatric surgery is consulted).

Thanks!

Keep in mind that CPT and CMS vary on their guidelines. The ability to report subsequent are codes are strictly regarding consultations and that rule was created by CMS for this specific reason. However, the provider must complete the consultation according to the requirements and guidelines for consultation coding before he/she would be eligible to bill for the admit.

CPT also states "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physician’s office, nursing facility) all evaluation and management (E/M) services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission [emphasis added]. The inpatient care level of service reported by the admitting physicians should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.” However, I could not find any supporting documentation from CMS that matches this with regards to consultations.
 
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