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on call hosp consults

Annmarie Posted Thu 31st of January, 2013 17:28:56 PM

which codes would be the appropriate ones to bill for when the Dr (cardiologist) who is on call in the hosp & gets called in to do a cardiology consult on a patient for IP & OP? These would be patients whom the Dr has never seen before & most likely than not, will never see again. thank you

SuperCoder Answered Mon 04th of February, 2013 20:15:44 PM


I am forwarding this query to my editor. She will get back soon with the reply.

Thanks for being patient.

SuperCoder Answered Wed 06th of February, 2013 09:35:48 AM

Please define your abbreviations IP & OP. They can stand for various words.

Thank you,
Jen Godreau, CPC, CPMA, CPEDC

SuperCoder Answered Tue 12th of February, 2013 19:15:18 PM

The following assumes you are not reporting consult codes due to Medicare's nonacceptance of them.

In the inpatient setting you should code the consultations with the appropriate hospital care code (99221-99233). The admitting physician should use modifier AI PRINCIPAL PHYSICIAN OF RECORD to indicate he is the physician of record. The different specialties and modifier AI should prevent any denials for duplicate hospital EM codes on the same day for the same patient.

In the outpatient setting, use office visit codes 99201-99205.

The following is the directive from the Medicare Claims Processing Manual, Chapter 12, section 30.6.10

30.6.10 - Consultation Services
(Rev. 2282, Issued: 08-26-11, Effective: 01-01-11, Implementation: 11-28-11)
Consultation Services versus Other Evaluation and Management (E/M) Visits
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed.
In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual. T he principal physician of record is identified in Medicare as the physician who oversees the
patient’s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” (Principal Physician of Record), in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits...
In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer.

Jen Godreau, CPC, CPMA, CPEDC

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