Conquering Consults Kim Reid,, CPC,, CPC-I,, CEMC Objectives Clearing up p cons consult lt conf confusion sion Understanding the consult requirements How do we code/document now that Medicare no longer recognizes consults 1
What is a Consult? A request from one Health Care Provider to another for their advice and opinion i regarding a patient s condition If the request is to a specialist, wouldn t EVERY initial visit be a consult? What is the difference between a new patient visit and a consult? When to Bill Consults There must be a specific request for a consult from one provider to another Can be verbal but should be documented where the request came from Confusion begins when the documentation is not clear as to what is being requested Can co-management be considered a standing request for a consult? 2
New Patient or Consult If the service was not requested by another provider, it can not be billed as a consult Patient heard the provider was the best in the field so they made an appointment on their own to be assessed Second opinion Follow-up visits New Patient or Consult Consults can be billed even if the patient is not new to the practice Consult may be billed whenever there is a request for advice and opinion Pre-operative exams Patient develops a new problem Same problem progresses beyond what was anticipated 3
Initiation of treatment What if treatment is initiated? Based on the provider s assessment, they are able to initiate treatment and still bill the service as a consult Not considered a transfer of care Requires a written document between two providers that states a transfer of care is taking place Medicare and Consults As of January 1, 2010 Medicare no longer recognizes consults An effort to level the playing field Shortage of Primary Care providers Eliminated consults and increased reimbursement for other E/M services across the board All providers will be reimbursed at the same rate 4
Outpatient consults for Medicare are now billed as new or established office or other outpatient services These are a one-to-one match in the documentation guidelines Advice and opinion regarding a new problem on a patient seen less than 3 years ago Alternative Coding Consults while the patient is in observation status t Since the patient is not admitted, they are considered outpatient so the same rules apply as office or other outpatient services 99201-99205 99212-99215 5
Emergency department visits Patients seen in the ER should be coded with the appropriate ER code (99281 99285) If assessed by an ER physician and then a specialist is called in to see the patient as well, both providers will bill the appropriate ER code If patient is admitted by the specialist, the specialist will bill the appropriate initial hospital visit code with an AI modifier Alternative Coding Initial Hospital Visits The attending of record uses Initial Hospital Visit codes (99221 99223) with an AI (not number one, but letter I eye) These codes can be used by multiple providers throughout the patient s hospital stay Except when providers are in the same group, same specialty 6
The documentation requirements for inpatient t services are NOT a one-to-one match to the consult codes Can lead to reduced payment due to insufficient documentation Only three levels for Initial Hospital Visit as opposed to five levels for consults Alternative Coding Code 99222 is a one to one match with code 99254 Code 99223 is a one to one match with code 99255 Code 99221 does NOT have a one to one match 7
Requirements for 99221 (3 of 3 key components) Detailed History Detailed Exam Straightforward MDM Best match = 99242 Expanded Problem Focused History Expanded Problem Focused Exam Straightforward MDM Alternative Coding What is the correct code to bill when the documentation ti does not meet the requirements for the lowest level of Initial Hospital Visit? Options: Unlisted E/M code Subsequent Hospital Visit Just bill the lowest level because there is not another option 8
At the 2010 AMA CPT Symposium CMS specifically stated t that t it would NOT be appropriate to bill an unlisted E/M service in this case We want to code for the work that was performed so we would not bill the service anyway Maybe we should not bill anything at all Alternative Coding We would be required to bill for a Subsequent Hospital Visit it when the documentation does not meet the requirements for a higher level code Depending on the documentation, either a 99231 or 99232 would be appropriate 9
Requirements for 99231 Problem Focused History Problem Focused Exam Straightforward MDM Requirements for 99232 Expanded PF History Expanded PF Exam Moderate MDM Solutions What is the solution to all this confusion? EDUCATION EDUCATION EDUCATION If the providers are not interested, keep track of the amount of times you have to reduce their coding due to insufficient documentation 10
Conclusion It is a good idea to get the providers to understand d the documentation ti requirements for all the levels of service Provider education is the key to understanding alternative consult coding options It is unknown if other payers will follow CMS in the elimination of consult services in the future Questions Do we have all our ducks in a row? 11