Wiki Orthopedic consults

[jweber86]

Hey all! I work for a busy orthopedic group who has PAs do orthopedic consults at the hospital..we were originally told when billing for orthopedic consults to use the 99221 range. Is this accurate? What if the patient has already been initiated by another physician. Should we be using another code set? Any help is greatly appreciated

 

[lburgos31]

If the provider is the admitting provider in an inpatient hospital setting, then they alone can use the 99221 coding range. All other consultants may use 99231,99232 for Inpatient Subsequent Hospital Care. If the patient is being Admitted as an Observation, then 99234-99238 can be used for subsequent observation care.

***The admitting physician performs the initial E/M service upon the patient at the time of admission as inpatient. This code can be billed only ONCE per day.*** (Obtained from Codify)

 

[csperoni]

I disagree. Whether or not 99221-99223 is appropriate can depend on the carrier.
When CMS eliminated consult codes, their official advice is the admitting bills 99221-99223 with -AI. Physicians who would have billed 99241-99255 should use 99221-99223. If the service provided does not meet the requirements for 99221, they may bill 99231-99233.
Remember this assumes meeting the 3Rs of consultation, which is not often the case. Just because another physician called in a specialist does not automatically make it a "consult" per the coding definition.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7405.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6740.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1010.pdf

Specifically:
-Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.
-In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

In my experience, most commercial carriers will allow another physician to also bill the initial 99221-99223.