E/M vs. Consult


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Our office handles trauma patients (hand). We have a hospital trauma service that is denying our claims when we bill with a 99231 or 99232. They state that we should be billing with a 99251 or 99252. Our office disagrees as the dr is not just giving his opinion but taking over the care for the hand.

We have all the documentation from the hospital service to back up our submission of the "corrected claim" with the 99251 or 99252. Should we continue to bill appropriately with the 99231 or 99232 and get the denial and then send the "corrected claim"? Or would it be appropriate to initially bill with the 99251 or 99252 as we have the documentation from the trauma service that they will only process payment under these codes?

Thank you for your responses,

I believe the the proper code MAY be the consult ... even if your surgeon winds up taking over management of that issue.

CPT 2008, Professional Edition, page 14 second paragraph of guidelines under Consultations:
"A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."

If you have access to the hospital chart, you might also find that the requesting physician has, indeed, placed an "order for consult by hand trauma surgeon."

So if your hand surgeon is being asked by another physician to see the patient in consultation re hand injuries, and the hand surgeon is reporting back to the requesting physician (easy to do in an inpatient setting, as the patient's chart is accessible to both), then the first visit could be reported as a consult. Don't forget the -57 modifier if there is a decision for surgery as a result of the evaluation, and it is performed the same or next day.

F Tessa Bartels, CPC, CPC-E/M