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TRANSCRIPT
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Conquering Consults
Kim Reid, CPC, CPC-I, , , ,CEMC
Objectives
Clearing p cons lt conf sion• Clearing up consult confusion
• Understanding the consult requirements
• How do we code/document now that Medicare no longer recognizes
consultsconsults
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What is a Consult?
• A request from one Health Care Provider t th f th i d i d i ito another for their advice and opinion 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• What is the difference between a
new patient visit and a consult?
When to Bill Consults
• There must be a specific request for a lt f id t thconsult 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?
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New Patient or Consult
• If the service was not requested by th id it t b bill danother 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 t “ ” t th tinot “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
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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 consultsrecognizes consults
• An effort to “level the playing field”– Shortage of Primary Care providers– Eliminated consults and increased
reimbursement for other E/M services th b dacross the board
– All providers will be reimbursed at the same rate
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Alternative Coding
• Outpatient consults for Medicare are now bill d t bli h d ffi thbilled 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 t tstatus– 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
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Alternative Coding
• 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 codeappropriate 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
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Alternative Coding
• The documentation requirements for i ti t i NOT tinpatient 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• 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 d 99254code 99254
• Code 99223 is a one to one match with code 99255
• Code 99221 does NOT have a one
to one matchto one match
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Alternative Coding
• Requirements for 99221 (3 of 3 key t )components)
– Detailed History
– Detailed Exam
– Straightforward MDM
• Best match = 99242Best match 99242– Expanded Problem Focused History
– Expanded Problem Focused Exam
– Straightforward MDM
Alternative Coding
• What is the correct code to bill when the d t ti d t t thdocumentation does not meet the requirements for the lowest level of Initial Hospital Visit?
• Options:– Unlisted E/M codeUnlisted E/M code
– Subsequent Hospital Visit
– Just bill the lowest level because
there is not another option
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Alternative Coding
• At the 2010 AMA CPT Symposium CMS ifi ll t t d th t it ld NOT bspecifically stated that 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 notwas 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 S b t H it l Vi it h thSubsequent Hospital Visit when the documentation does not meet the requirements for a higher level code
• Depending on the documentation,
either a 99231 or 99232 would beeither a 99231 or 99232 would be
appropriate
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Alternative Coding
• Requirements for 99231– Problem Focused History
– Problem Focused Exam
– Straightforward MDM
• Requirements for 99232Expanded PF History– 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 timeskeep track of the amount of times
you have to reduce their coding
due to insufficient documentation
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Conclusion
• It is a good idea to get the providers to d t d th d t tiunderstand the documentation
requirements for all the levels of service
• Provider education is the key to understanding alternative consult
coding optionscoding options
• It is unknown if other payers will
follow CMS in the elimination of
consult services in the future
QuestionsDo we have all our ducks in a row?