Wiki Inpatient consult codes

[AN2114]

I am confused on what to do for inpatient consult codes for the first consultation the doctor has with a patient. Some articles say to use 99221-99223 and then some say not to use that but 99251-99255 instead and vice versa. I have read that cpt code 99221-99223 is to only be used by the admitting physician. I received a rejection from bcbs stating they do not recognize 99251-99255 as consultation codes. So should I be using 99221-99223 for the first consult our doctor has with a patient even if he's not the admitting physician? Or do I stick with codes99231-99233? I'm confused because I can't find solid information about which one I should be billing for the first consultation.

 

[agibbons]

CMS does not recognize Consult codes and instead wants you to use either Initial or Subsequent Inpatient codes. Go to Medicare Claims Processing Manual chapter 12, section 30.6.8 and 30.6.9 Payment for Observation and Payment for inpatient hospital visits and 30.610 consultation services. Blue cross of Iowa and most of our payers follow this guideline (except Aetna on Observation services), you will need to check your specific payers manual to verify but it sounds like the BC you are billing follows CMS.

 

[Orthocoderpgu]

You need to be careful using the word consultation. If the three "R"s of consultation are not documented, it's not a consultation. Just because your doctor is asked to see a patient does not make it a consultation.

 

[Birdie625]

My question is IF the note does not qualify for a consult, and the level does not meet the minimum initial IP, can I do a subsequent instead? I know CMS said back when, they would give the provider the chance to do a subsequent IF it was a consult as the 'consult' might not meet requirements for the Init IP level. However, the notes I see do not qualify for the 'consult', and it is the initial visit, so I have been working on the concept of no, cant use a subs for the initial if it does not qualify as a consult. (Too early in a.m., I'll probably re-see this and think geezzzz 'what was I talking about')

And to comment re: orig post if pt is in IP status and the M.D. sees pt, I do code a 9922x code based on documentation and the reference given in another's post is a great place. The admitting/attending would need to append modifier AI.

 

[Orthocoderpgu]

The initial inpatient evaluations 99221,99222, 99223 require all three key components are met. If the documentation does not support all three key components on the initial evaluation, I think by default the only option is to drop down to the subsequent codes 99231, 99232, 99233. I think I read something about doing this years ago but can't remember my source now. You can never report a consultation code if any of the requirements are missing. CMS actually reached out to coders in every way that they could on what needed to be documented for a consultation. When CMS first started auditing consultation codes the failure rate was 95%. After three years of reaching out to coders there was no improvement, the failure rate was still about 95%. This is why CMS no longer makes payment on consultation codes with most private payers following CMS now.