Wiki Consultation Confusion!

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deanad77373

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I have a provider (Hemologist/Oncologist) who is still confused:

If a patient known to his office gets admitted to a hospital, and then he is requested to 'consult' on the patient, should he code the 'Initial Hospital- Admission H&P: 9922X' series or is the patient considered an 'established patient' and therefore the Subsequent Inpatient 99223X series.

We have tried to contact the local MAC carrier (Cigna) but have yet to get a response. Any guidance or research documentation is greatly appreciated.

Thank you,
 
deanad77373 said:
I have a provider (Hemologist/Oncologist) who is still confused:

If a patient known to his office gets admitted to a hospital, and then he is requested to 'consult' on the patient, should he code the 'Initial Hospital- Admission H&P: 9922X' series or is the patient considered an 'established patient' and therefore the Subsequent Inpatient 99223X series.

We have tried to contact the local MAC carrier (Cigna) but have yet to get a response. Any guidance or research documentation is greatly appreciated.

Thank you,
Click to expand...

Trying to find information with Cigna...Psssh! :rolleyes: Good luck!
If your doctor admits the patient, he should bill the initial hospital admission code. If someone else admitted them, then he needs to bill a subsequent inpatient code. The patient is established, regardless of who admitted them, because your doctor has already seen them (location doesn't matter). Hope that helps!
 
Now I am confused, location does not matter?

CMS Publication 100-4, Chapter 12: 30.6.10 - Consultation Services (Codes 99241 - 99255)
(Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10)

"In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). The principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI”, Principal Physician of Record, in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits. ). "
 
Inpatient consultations

Inpatient Consultations are for New or Established Patients. If your patient's PCP or ER doctor admits the patient, then requests a consultation from the specialist, the specialist can bill the consult code regardless of whether the specialist has seen the patient before in another setting. The specialist's subsequent inpatient visits are then billed with the subsequent hospital care codes.
 
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consultations

If the patient is Medicare, regardless of whether they are new or established, the first inpatient visit for that admission by any physician would be coded using the initial inpatient E&Ms 99221-99223, providing their documentation meets the requirements for these codes. Any subsequent visits by that physician during that admission would be coded using 99231-99233. If the patient is not Medicare, you could still use the consult code for the first visit and then the subsequent hospital codes for any other visits.

LeeAnn
 
BoeJerger said:
CMS Publication 100-4, Chapter 12: 30.6.10 - Consultation Services (Codes 99241 - 99255)
(Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10)

"In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304 – 99306). The principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI”, Principal Physician of Record, in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits. ). "
Click to expand...

Location doesn't matter to whether or not the patient is new or established, as far as your physician is concerned...Let me explain...

If your doctor works out of more than one location, and sees a new patient at location A, but then sees them a week later at location B, you do not get to bill another new patient code, just because they were seen at a different clinic/location. They are established to that doctor, no matter where he goes. Make sense?
 
consultation

You are correct, however the initial question was regarding the initial inpatient visit, and per Medicare, the initial inpatient encounter for each admission should be charged using 99221-99223 (if documentation meets) regardless of whether that physician has ever seen the patient before outside of that admission.

LeeAnn
 
You are correct as well!:D
I just wanted to clarify what I meant by "location doesn't matter" in a previous post, since it was causing confusion.
 
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