Question Can a Specialist Code a Consult with Prolonged Services?

ealasaid76

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I'm coding a consult for a cardiologist and he coded prolonged services that included: ~15-20 minutes face-to-face with the patient, speaking to her about her condition and a treatment. He included about that amount of time for reviewing her chart and speaking to the referring physician over the phone. Is this all included in the consult code, or is he right and I'd add on a prolonged service code in addition to the consult code? I've been looking everywhere online for documentation saying that, but I can't find any. Anyone? Is he overestimating time? I asked him his timeline / time spent in a query.
 

Orthocoderpgu

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I have a question for you. When you say "Consultation" are you referring to an actual consultation, or just an E/M to evaluate the patient. A consultation has three separate requirements. If any of those three are missing, you can't bill a consultation code. Most payers don't process claims with consultation codes any longer.
 

ealasaid76

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I have a question for you. When you say "Consultation" are you referring to an actual consultation, or just an E/M to evaluate the patient. A consultation has three separate requirements. If any of those three are missing, you can't bill a consultation code. Most payers don't process claims with consultation codes any longer.
Their PCP requested the consultation. This is a government agency facility.
 

thomas7331

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Prolonged services codes are add-on codes - they're to report time spent in addition or in excess of the consultation. To bill a prolonged services codes, you'd first need to bill the E/M service based on documentation and then determine if the excess time is sufficient to warrant the additional code.

Here's a good article on this site that explains this. (Of note, reporting prolonged time for non-consultation outpatient E/M services has changed as of this year and there are new codes and rules if you're billing from the code ranges 99201-99215.) On Table A in the article, you'll see the time requirements for reporting prolonged services in conjunction with consultation codes.

 

Orthocoderpgu

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Their PCP requested the consultation. This is a government agency facility.
Just because the PCP has requested that a patient see your Cardiologist does not make this a consultation. As stated before a consultation has three separate requirements. And most insurance companies don't process consultation codes any longer. Being a government agency facility has no impact. Are you sure that you have met all three requirements for a consultation? Just trying to help you out here.
 

SharonCollachi

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In addition to what Orthocoderpgu said, I always ask, "did the requesting physician ask for your opinion on a particular problem?" In your case, it would look something like this:

Dear Cardiologist, My patient, Mr. XX, has a QT prolongation and is currently taking buprenoprhine 10mcg bid. Please review and advise on this regimen for this condition.

See what I did there? Asked for an opinion. Didn't just say, "Consult and Treat".
 
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