Wiki Hospital Consults for Orthopedics Practicess

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swallace1

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I have recently been tasked with billing consults (call coverage) for a medical orthopedic practice, it's been a while, and I want to make sure I understand the current guidelines.
Here are my "burning questions":

If the patient is seen by Ortho MD in the ED and then admitted to Observation status for dx of fracture care do I bill CPT code ED (99281-99285) or do I bill Initial Hospital Inpt or Observation care (99221-99223)? I think I should be billing the Initial Hospital Inpt or Observation- because, based on dx Ortho will most likely be the lead MD on the case, and POS should be OP, because the patient was admitted to Observation. or should it be Emergency Department because that is where consult took place?

If an Ortho MD sees in ED for an ortho-related dx, and the patient is admitted by a hospitalist for medical conditions. I would bill the ED codes, with the POS of the Emergency Dept? -even if the patient is admitted as an inpatient?

What if a general Ortho MD sees the patient in the Emergency Department, the patient is admitted to the hospital and then the general Ortho MD that saw the patient in Emergency Department, requests a consult from the Hand Specialist (same practice) to see the patient on a subsequent day. Can I bill for both Ortho consults? Is one initial and the other subsequent (99231-99233) or are both initial?

It is all a bit of a quandary for me. I greatly appreciate the support and/or suggestions for reference materials.
 
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I bill hospital on-call requests/consults for a neurology/neurosurgery practice and if a patient is seen by one of our providers in the ED, I use the ED codes and the ED POS because that is where the consult took place, regardless of where the patient currently is. Then, I bill the admission to observation/inpatient codes separately if the patient gets admitted to either observation or inpatient status and is seen again during that status.

I can't speak to your question regarding the Hand Specialist, but I believe it depends on how both providers are credentialed with the insurance company for that particular patient regarding if they can both be billed as initial or not.
 
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Thanks for the response. I pull the information below from CMS manual. It is confusing to me- seems like, if patient comes into the Emergency Room and is subsequently admitted either inpatient or observation- I should be billing the initial hospital care code, even if the patient is seen in the Emergency Room. Any suggestions?

If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met (Was this a consult request?). If the criteria for a consultation are not met and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.
 
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Right.

If the patient gets admitted to inpatient status after having been seen in the ED, the next visit (on a following day after being seen in the ED) would be billed as a subsequent inpatient code 9923x without initial inpatient code.
 
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So, if the orthopedic doctor is requested to see the patient in the ED by the ED attending, and then is admitted- I would bill the visit using an initial hospital visit code, with a POS of inpatient or outpatient for observation status.
I should only apply the emergency room CPT codes when the patient is discharged from the ED?
 
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As long as the patient is admitted to the ED and your providers are seeing them in the ED, you can report the ED codes is my understanding. If the first visit is in Inpatient status, then you would code the initial inpatient codes, but if the first visit is the Emergency Department, then that would be the ED codes until admitted as Inpatient or Observation statuses, which would be coded as subsequent inpatient/observation
 
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Ok. I am confused. So if my provider is a general surgeon called to the ED to consult and then does a procedure-but discharges the same day we are using the ED code set for my surgeon? I always thought since a procedure was performed the consult/ED charge is not billable. I just wish there was somewhere to input our scenario and the answer comes right out. Maybe if I find a Genie in a bottle that can be one of my wishes.
 
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My understanding is that you can bill BOTH the consult and the procedure if there is documentation to support both. For example, the surgeon sees the patient in the ED, dictates a consult, then performs procedure/surgery and dictates that as well. Bill for both, and apply modifier 57 to the ED or initial visit code, depending on which one you are billing.
I have multiple other questions for the "genie" like...
It seems disjointed, to bill an ED visit with the ED place of service and then bill for the surgery under the inpatient/observation status. I always thought once a patient was admitted, the time spent in the ED acts as the beginning of the encounter/admit date.

What if the physician doesn't state where he/she, saw the patient- in the ED or on the floor- I review the ED notes to determine, if there is anything in that note, that will help me determine.

The fact, that most patients are admitted to the "hospitalist" leads me to think that any visit by the surgeon in the ED should be billed with a CPT code for an ED visit and Initial Hospital care should be used when the patient is seen on the floor.

What about dictated progress notes? Can they be billed using the Subsequent visit code?

We don't usually get the dictated discharge summary, so how do you tell if patient was an inpatient and use that place of service code, versus an Observation status, and use the outpatient place of service code.

Lots of questions, for the "genie".
I will keep digging and I appreciate all the responses.
 
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Read this: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
It breaks down the scenarios and has examples (if you are billing to MCR or a payer that follows MCR).
If talking ED: 30.6.11 - Emergency Department Visits (Codes 99281 - 99288)
F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting
If the emergency department physician requests that another physician evaluate a given patient,the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Also, be sure to read the guidelines at the beginning of each code set section in the CPT book. It explains when to report the codes and if not, directs you what to report instead.

It depends on who the admitting provider is. You would have to have access to the hospital record to see what the disposition of the patient was (ED/OP, OBSV, IP). In my orthopedic experience, it is not usually the ortho provider that is the admitting, but it does happen. Normally the hospitalist is the admitting and the ortho is a consulting provider. There are a lot of scenarios.

Speaking of dictated progress notes, it depends. This is also called rounding. If the patient is admitted, and in a global, what is the provider doing? If it is part of the global you can't bill for it however, if it is a different injury/condition you could bill subsequent. For example a multi-trauma patient who had surgery on an ankle fracture from day 1 now in global but on day 4 complains of shoulder pain. Is there enough documentation/treatment in the rounding note for the shoulder? You may get a subsequent E/M.

You are going down the rabbit hole of multiple different scenarios. If you break it down per patient and stay it will make more sense, don't mix it all together. If you don't have access to the hospital record/EHR it will make it much more difficult to code for the ortho provider because you won't see the "whole" picture. There were times in my experience where we had to wait and pause the billing and coding because the patient was inpatient for a period of time, it takes some time to get the full stay picture. I have also always had access to the hospital record, so I could see the entire record. If you are piecing together bits and pieces only by what the ortho doc does and only their documentation, it is much more difficult.

Some of the MACs have decision trees to help you: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00159301

This costs money but would be well worthit if you only code orthopedics:
 
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Thanks so much for the wealth of information. The KZA seminar is not currently available for registration and it looks like a great resource.
I appreciate your response.
 
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