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History and physcical vs Consultation billing

  1. Default History and physcical vs Consultation billing
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    Hello,
    Can someone help with the following scenarios?

    A general surgeon who is on call or who admits the patient from the ER.
    The general surgeon who I code for has been billing the H&P using the inpatient consult codes.(99251-99255) he says another doctor calls him to see the patient. The H&P report does not specify a requesting doctor and on the face sheet it says the general surgeon is the admitting doctor. In my opinion, I should code the the initial hospital codes 99221-99223, and If he should do a surgery, append a modifier 57 to the vist. The physcian insit he can bill the initial inpatient codes.

    Also in the surgery guidelines in the CPT book, when it says, the surgery includes the H&P immediately prior to surgery and the subsequent imediately prior to surgery.Does this H&P refers to when the patient comes into the office and and has his/her preo visit? (This is the one you don't charge right?) Now when the patient is in the hospital and has been admitted and the physcian does the H&P, this is the one I can charge right? ( But the issue was if I should be using the Inital hospital or inital inpatient codes for this H&P.

    Second scenario:
    If the physcian does an initial consultation on 4/10/09 and recommends surgery, but the surgery will be contingement on more test, once the test are confirm, then he will make his decision. The test reults came, the doc decides to perform the surgeryhe initially recommended. He does a susequent visit on 4/11/09, and documents decision for surgery. Do I charge the initial consult with a 57 even though his decision for surgery was not final, and not charge the subsequent vist as this would be included?, or do I not charge the initial consult and bill the subsequent with a 57 since his decision was final on the subsequent vist? In the past, for this scenario, I have been billing the initial consult and including the subsequent in the surgery.

  2. #2
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    See my responses in purple...

    A general surgeon who is on call or who admits the patient from the ER.
    The general surgeon who I code for has been billing the H&P using the inpatient consult codes.(99251-99255) he says another doctor calls him to see the patient. The H&P report does not specify a requesting doctor and on the face sheet it says the general surgeon is the admitting doctor. In my opinion, I should code the the initial hospital codes 99221-99223, and If he should do a surgery, append a modifier 57 to the vist. The physcian insit he can bill the initial inpatient codes.

    Just because another doctor "calls" him to see the patient, doesn't mean it's a consultation. Especially if the ER is calling him. The ER tends to "pass the buck" they aren't asking for the surgeon's advice/opinion. They are passing the patient from the ER service to the general surgery service. Who actually writes the order for admission? You said the hospital has the general surgeon as admitting. It would be inproper to bill the "consult" codes. He should be coding the initial hospital codes, 99221-99223. If your physician, at that time, decides surgery is warranted, yes, you would append modifier 57 to that visit.

    Also in the surgery guidelines in the CPT book, when it says, the surgery includes the H&P immediately prior to surgery and the subsequent imediately prior to surgery.Does this H&P refers to when the patient comes into the office and and has his/her preo visit? (This is the one you don't charge right?) Now when the patient is in the hospital and has been admitted and the physcian does the H&P, this is the one I can charge right? ( But the issue was if I should be using the Inital hospital or inital inpatient codes for this H&P.

    The E/M that resulted in the decision for surgery with modifier 57, is usually carved out of the global. Some carriers won't pay if it is the same day as the surgery. You will need to check with the payer on this. The visits after the decision for surgery are considered global, unless something unrelated to the surgery comes up. It is not appropriate to charge for office visits that are your normal, routine, postoperative care.

    If the physcian does an initial consultation on 4/10/09 and recommends surgery, but the surgery will be contingement on more test, once the test are confirm, then he will make his decision. The test reults came, the doc decides to perform the surgeryhe initially recommended. He does a susequent visit on 4/11/09, and documents decision for surgery. Do I charge the initial consult with a 57 even though his decision for surgery was not final, and not charge the subsequent vist as this would be included?, or do I not charge the initial consult and bill the subsequent with a 57 since his decision was final on the subsequent vist? In the past, for this scenario, I have been billing the initial consult and including the subsequent in the surgery.

    In this scenario, you would bill the E/M on 4/10/09 with no modifier. Then when the decision for surgery is actually made after testing on 4/11/09, you would use the modifier 57 on the subsequent visit. I think by you adding the 57 to the initial visit and not the subsequent visit, you've been short changing yourself, because you should get reimbursed for both services, the initial and subsequent. After that subsequent visit with modifier 57, the global clock starts ticking.

    Hope that helps.....

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