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Consult versus H&P

  1. #1
    Exclamation Consult versus H&P
    Medical Coding Books
    Does anyone know of any documentation <CMS> where it explains that even if a physician is called to the ER for a consultation if he/she ends up admitting the patient to their service it is coded as an H&P. My docs want the reimbursement for the consults v H&P and I need something in black and white to show them what they are doing is wrong. Thanks SO Much!!

  2. #2
    This sounds like an obvious transfer of care to me. In which case you do not met the criteria for a consult at all.

    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 a consultation if the criteria for consultation are met. 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.

    Laura, CPC

  3. #3
    Milwaukee WI
    Default CPT Guidelines
    2009 Professional edition CPT, page 12, top of second column:
    When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. hospital emergency department ...) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    thus the proposal to "nuke" the consult codes in 2010! The reimbursement for a consult is significant and the criteria is ill-defined or misunderstood and the result is consult charges being submitted erroneously. Just my opinion, after much debate and discussion with non-coders at my place of employment.

  5. Default
    I've read that if a physician is asked to consult in the ER and later that day admits the patient, the consulting physician is allowed to bill either the consult or admit charge. It is up to their discretion. I will try to find out where I read that. It may have been in an AAPC newsletter actually??

    I don't agree that this is an obvious transfer of care. If the ER doc wanted the opinion of your doctor, it probably meets the criteria for a consult regardless of whether your doctor admits the patient or not.

    Lisi, CPC

  6. #6
    North Carolina
    I agree with Lisi on the "either/or" scenario.

    Initial Hospital Care From Emergency Room

    Contractors pay for an initial hospital care service or an initial inpatient consultation if a physician sees his/her patient in the emergency room and decides to admit the person to the hospital. They do not pay for both E/M services. Also, they do not pay for an emergency department visit by the same physician on the same date of service. When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

  7. #7
    Greeley, Colorado
    One would have to consider whether or not the requesting ED physician was truly asking for a consult or if he/she really wanted the "requested" physician to assume care and ultimately make the decision on admission or not. My opinion is that usually the ED provider is asking for someone else to assume care, but that is not always the case.

    I for one, will be happy to see consultation codes go away.
    Lisa Bledsoe, CPC, CPMA

  8. #8
    I agree with Lisa Curtis on this one. These "consults" are generally transfers of care.

    My surgeons will have a fit if they get rid of consults but it will make my life a lot easier!

    Laura, CPC

  9. Default
    Amen to getting rid of consult codes.


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