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Orthopedic Coding Alert

Reader Question:
Is This a Consult?

Question: A cardiologist admitted one of my arthritis patients to the hospital. The cardiologist requested that I see the patient to help manage methotrexate (J9250) administration pre- and postoperatively. The chart states that I am consulting, but I don't know if I can bill a consult because I know the patient and have seen her in my office many times. My office manager told me that each doctor following the patient in the hospital has to have a different diagnosis unique to the problem he's  addressing with the patient to ensure reimbursement. Is this accurate?

Virginia Subscriber Answer: Your physician's hospital visit would not meet consult criteria (99251-99255, Initial inpatient consultation for a new or established patient ...) because the cardiologist asked you to manage a particular aspect of care - the methotrexate administration -- and not to render an opinion, which a true consult requires. You should submit a code from the 99231-99233 range (Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Regarding the different diagnoses, orthopedists are no longer required to treat a different diagnosis than the other physicians ministering to the patient. If a patient with one diagnosis requires two physicians of different specialties, then you can each report your own service linked to the same diagnosis code, as long as the services are both medically necessary.

Trailblazer Health Enterprises, a Part B carrier in Virginia, refers to this situation as "concurrent care" and requires that you clearly define each physician's role.

Trailblazer's policy states, "Coverage can be allowed if each physician's services are established as reasonable and necessary as the result of an active concurrent role in the patient's treatment. This requirement can also be fulfilled if the patient's condition warrants the services of more than one physician on an attending rather than a consulting basis and all are determined to be reasonable and necessary."

In your case, the patient's heart problems and rheumatoid arthritis (714.0) would most likely justify both specialists' services.


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