Gail Pfeiffer

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

1. When should the observation code be used? Do the provider and facility need to use the same codes in order to be reimbursed for observation? What are the restrictions, if any, on what diagnoses may be used to bill for observation?

Observation status is an “outpatient status” even if the patient is located in an inpatient bed. The purpose of observation is to allow the physician time to make a decision about whether the patient should be admitted, and then rapidly move the patient to the most appropriate setting—i.e., the patient should either be admitted as an inpatient or sent home.

Therefore, only the physician who writes the order that places the patient in “observation status” and is responsible for the patient during his or her stay should use the observation codes. Always date and time the “admitting order,” because this information is needed to meet the minimum 8-hours rule if the patient is admitted and discharged on the same calendar date.

If a patient is both admitted and discharged on the same calendar date, the code range of 99234-99236 are used; however, the following criteria must be met:

1. The patient must be in observation for a minimum of 8 hours.
2. The billing physician must be present and show active involvement by charting condition updates, orders, etc.
3. Both the admission and discharge notes are written by the billing physician (or may be billed by 2 physicians within the same group practice).

The specific CPT observation codes (99218-99220 and 99234-99236) do not have to match those used by the facility, because the physician codes are based on the physician E&M criteria (i.e., extent of history, exam, and decision making). The facility’s use of these codes is based on facility-specific criteria that measure the resources used by the facility’s employees and does not relate to the physician’s evaluation.

There are diagnosis/condition restrictions for separate payment to facilities for observation under the Outpatient Prospective Payment System (OPPS) reimbursement program (i.e., payment is based on Ambulatory Patient Classification [APC]). Even though separate payments for observation charges are made only for chest pain, asthma, and congestive heart failure, the facilities still code and report charges for all patients admitted to observation status. Note, however, that there are no such restrictions for the physician professional services billed. Only hospital facilities are subject to the diagnosis restrictions because of APC payment rules.

2. How should a change in status from observation to full admission affect coding (i.e., when this occurs, what should the appropriate coding be for the initial hospital day or for the second hospital day)?

The best way to answer this question is with some scenarios.

Scenario #1:

The patient is admitted to observation status after being evaluated in the ED. The attending physician writes an order “admit to observation status;” writes an admit note, which includes the intent of observation; and writes orders to help determine if the patient is to be admitted or sent home. After test results return, the physician decides to admit the patient on the same calendar date:

Code: Initial Hospital Care code (99221-99223) that incorporates all services (observation and admission note) provided and documented that day.

Scenario #2:

The patient is admitted in the evening (Day 1) to observation status, tests are performed, and results are pending. The following morning (Day 2), based on the results of tests, the physician evaluates the patient and decides to admit (writes admit order). On Day 3 the patient is evaluated and discharged home.

Code:

Day 1: Initial Observation Care (99218-99220)

Day 2: Initial Hospital Care (99221-99223)

Day 3: Discharge Management (99238 or 99239)

3. Is it acceptable to bill for a d/c day if the patient is not examined that day, but activities such as d/c planning and dictation occur?

Discharge management codes do require the face-to-face evaluation/examination of the patient. Also included is the time spent on instructions to the patient/family, coordination of care with other providers, preparation of discharge records, prescriptions, referrals and/or certification forms, etc. The dictation of discharge summary is not typically included in this definition, because it is usually considered a hospital requirement as opposed to something needed for the patient’s care.

4. How frequently should discharge code 99239 be used? What elements of the d/c process can/should actually be used toward the “greater than 30 minutes” definition? (e.g., do filling out the d/c paperwork, dictating d/c summary, phone time arranging f/u, etc., count?)

There is not a specific “frequency” for any code, although most payers will compare utilization of codes to “peers” of the same specialty. While this helps them identify outliers, it does not necessarily mean someone is coding incorrectly. It does mean that high utilization by a physician will probably result in some sort of “audit” or request for supporting documentation. For instance, if a physician has a high volume of patients who go to nursing homes requiring a lot of coordination of care, referral forms, etc., it may be expected that the physician may have a higher frequency of 99239 discharge management codes. For patients who are going home with great family support and are relatively healthy, it may not seem as “reasonable and necessary” to have greater than 30 minutes of discharge management, especially if every chart is documented with the same “35 minutes.” Therefore, try to keep track of the time devoted to these services as accurately as you can, and document the actual time and sufficient information to support the use of 99239.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.

Introduction

Hospitalists often have questions related to coding for consultative services and subsequent hospital visits, especially when other specialists are managing the patient “concurrently.” If the hospitalist is practicing in a teaching hospital the guidelines can be yet more confusing, due to the need to apply Medicare’s teaching physician guidelines. Even after reading informative articles or attending educational sessions, hospitalists may encounter unique scenarios that can frustrate the most experienced physician and/or coder. The goal of this article is to present some basic principles regarding coding for consultations and concurrent care, and to provide several case scenarios that can be applied in clinical practice as a guide.

Objectives of the article include answering the following questions:

• Is it appropriate as a hospitalist to bill a consultation code when requested by a surgeon who really wants you to manage the patient’s chronic medical conditions?
• Can a hospitalist charge for services provided to a postoperative patient at the request of the surgeon, even though there are no real medical conditions or complications?
• Can two internists (different subspecialties) treat and bill the same patient on the same day and get paid?
• Can two internists (same specialty) treat and bill the same patient on the same day?
• What if my group performs preoperative evaluations and will also be managing the patient postoperatively for his/her medical conditions? When the surgeon requests a “consult” may I use the consultation codes?

Consultations

An inpatient consultation is a service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem(s) is requested by another physician. There has been a tremendous amount of confusion in interpreting the rules regarding consultations in general, and this is particularly true for hospitalists given frequent blurring of the distinction between classic consultation and co-management. In August of 1999, Medicare clarified for its carriers when an encounter qualified as a consultation. Here’s what the manual states:

Consultation followed by treatment: “…Payment for a consultation may be made regardless of treatment initiation UNLESS A TRANSFER OF CARE OCCURS. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of the transfer of care in advance. “ (reference MCM 15506 B.)

Inpatient consultant services are coded using initial consult codes (99251-99255).

Scenario # 1

A psychiatrist asks you to see a 36-year-old man for “uncontrolled hypertension” who was admitted with a manic episode. The patient stopped taking his anti-hypertensive medications 6 weeks before, and his systolic blood pressure has been consistently running 160–170 since admission. You perform an in-depth review of his medical records, along with a thorough history and physical examination (made challenging by his poorly controlled mania) and review of his laboratory studies. After your evaluation, you agree to manage the patient’s hypertension problem.

Question # 1: Should this be coded as a consultation or a subsequent visit?

Answer: Since a request was made to evaluate a patient for a problem and you did not in advance of the consultation (in writing) accept transfer of the patient’s medical care, a consultation may be coded as long as all of the criteria have been met. The fact that you decide to manage the patient’s hypertension subsequent to the initial consult does not impact your ability to use the initial consult code for this patient. Remember the requirements for a consultation—

• Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
• Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)

Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?

Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.

Scenario # 2

A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.

Question: Can I code an initial consult?

Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.

Postoperative Management of Medical Problems

According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?

Concurrent Care

Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”

• The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
• Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.

Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).

Scenario # 3

A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.

Question: Does this meet the definition of appropriate concurrent care or a consultation?

Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.

Scenario # 4

A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”

Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?

Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.

Scenario #5:

The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.

Question #1: What must be done documentation-wise by the attending physician to ensure that the optimum billing level is captured for this patient? What is not acceptable in this setting?

Answer: Redocumentation by the teaching physician is relatively minimal since CMS revised its guidelines [Transmittal 1780 dated 11/22/02], which allows substantial reference to the resident’s note in addition to a personal note, however, documentation must clearly demonstrate that the teaching physician was physically present during the key portions of the service billed. Examples of documentation provided by CMS are:

“I performed a history and examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Or

“I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.”

Or

“I saw and evaluated the patient. I agree w/ the resident’s note except…” while noting the difference in plan, etc.

Question #2: If the hospitalist/medical resident write the orders for the heparin and V/Q scan, does this constitute comanagement and prevent billing this as a consult?

Answer: A consultant may initiate treatment at the conclusion of his evaluation and still bill a consultation code as long as the other requirements have been met (i.e., a request for opinion regarding evaluation and treatment and no advance transfer of care). There are no specific rules related to medical residents in this scenario, so if the teaching physician is performing the consult in a timely manner with the resident, a consultation could still be coded appropriately.

Summary

Although efforts have been made by Medicare to clarify the vagaries of coding for consultative work, existing guidelines remain complex and not necessarily intuitive. This article has attempted to shed light on some of the more commonly encountered situations with which hospitalists grapple, but is unable to address all of the questions that may arise. Hospitalists and hospital medicine groups are encouraged to familiarize themselves with current coding guidelines and to establish and maintain strong relationships with local coding professionals. Future issues of The Hospitalist will tackle additional coding questions.

Dr. Pfeiffer can be contacted at pfeiffg@ccf.org.