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CONSULTS

INTRODUCTION

Medicare stopped paying for the consult codes [99241-99245, 99251-99255] January 1, 2010. The consult codes paid more than their corresponding inpatient follow-up [99231-99233] and outpatient visit [99201-99215] alternatives, but came with very specific, but strict and confusing, situational and documentation criteria to allow for their reimbursement. Although Medicare stopped paying for the consult codes, they did not stop paying for consult services. The concept of needing the expertise of another provider is still essential to the practice of medicine. What has changed is how those services need to be reported for reimbursement to Medicare. Some private payors still reimburse for the consult codes, using the old Medicare situational and documentation guidelines, but these numbers are decreasing. Until 100% of insurers stop paying for the consult codes [99241-99255], two different payment systems for consults exist. Thus, the same work provided to two identical patients may be reimbursed differently depending on the patient’s insurer.

MEDICARE PATIENTS AND THOSE INSURERS FOLLOWING MEDICARE CONSULT RULES

The set of codes submitted for a consult to a Medicare patient is based on several variables: inpatient versus outpatient status, disposition after being seen in an emergency room (eventual admission vs observation status vs discharge home), and whether a patient is new or established to the physician specialty and billing group. (See Figure 28-1.)

Figure 28-1

Algorithm for selecting the proper CPT code set for mediCARE consults in a hospital setting. (Copyright 2010, Yvette M. Cua, MD. Used with permission.)

INPATIENTS

Initial consults for patients in acute care hospitals and skilled nursing facilities (SNF) are billed with the same initial inpatient visit codes used for admissions [99221-99223 (initial inpatient visit), 99304-99306 (initial SNF visit)]. All subsequent consult visits are billed using the subsequent inpatient or SNF visit codes respectively [99231-99233, 99307-99310]. The final day seeing the patient as a consultant will still be billed using the subsequent inpatient and SNF codes, even if the consultant is contributing to or fully providing the patient’s discharge management. Only the admitting physician/billing group can bill for discharge management services [99238-99239]. Medicare will only pay for medically necessary visits and not just daily “routine” visits because the patient is still in the inpatient hospital or SNF.

If a new problem or question surfaces, or the consultant is reconsulted during the same inpatient admission, with or without a time lapse since the last consultant visit, a subsequent inpatient/SNF visit code [99231-99233, 99307-99310] would be submitted for this service.

If a consultant is asked to see a patient whom they provided a consult on during a previous admission, even with the same problem(s) as last admission, the consultant would still bill an initial inpatient/SNF visit code [99221-99223, 99304-99306] for this work.

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