Wiki Determining A Consult Level

[kfrycpc]

Hi all,

I'm a little confused when it comes to determine the level for a consult and also for inpatient.

For a consult, I know 3 of 3 have to be met. If you have a C History , C Exam and H MDM, what would the level be?

For an inpatient, I know 3 of 3 must be met. But if they are not, and say you have a D/C History D/C Exam and M. MDM, how do you determine what the level is?

How about subsequent hospital (even though 2 are needed)?

I've had to teach myself all of this and have learned alot but these three instances confuse me.

TIA for any help,
K

 

[LoriCox]

E&M

E&M levels can be tricky if you are new to them. I would suggest getting a really good audit tool to assist you.

For your consult example, this would be a 99245/99255, because you have met the 3 required elements. Remember that Medicare doesn't pay these. In addition, you should be sure that the medical necessity requires this high of a visit - a patient with a simple cold would not be a level 5.

For the inpatient, for the initial hospital care, you would bill 99222. You can't bill a 99223 because your MDM is not high.

For subsequent hospital care, you only need to meet 2 of the elements. So if you have a EPF history and EPF exam, and a Low MDM, you should still bill a 99232 because you have met the 2 elements needed. Some payers and facilities require the MDM to be 1 of the 2 elements however, so if that were the case and you have to use MDM as one of the 2, then you would have to bill a 99231 for this example.

Go to the highest level and work your way backwards until all your required elements are met.

Hope that helps!

 

[kfrycpc]

Go to the highest level and work your way backwards until all your required elements are met.

Hope that helps!

Could you expand on this a little more?

 

[Sandy Stevens]

Excellent explanation Lori.