Coding Corner: How to report a consult service when your payor doesn’t accept consult codes

April 02, 2019
Area(s) of Interest: Practice Management Payor Issues and Reimbursement 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

It’s been nearly a decade since Medicare has accepted claims for either outpatient (99241-99245) or inpatient (99251-99255) consultations. In recent years, private payors have followed suit: Health Net no longer reimburses consultation services and UnitedHealthcare has announced its intention to stop recognizing the consult codes, as well. This begs the question: How are providers to bill for consultation services that can’t be reported as consultations?

Outpatient alternatives

In the office or outpatient setting, in place of consultation codes 99241-99245, you should report the appropriate Outpatient Services code (e.g., 99201-99215 for office outpatients). The service must be supported by the key components of history, exam and medical decision-making (MDM); or time, if counseling and/or coordination of care dominate the encounter.

For example, a surgeon sees a new Medicare patient in the office for a consultation for another provider in the area. The surgeon will bill the consultation visit as a new patient visit at the appropriate level using 99201-99205. For instance, to report 99203 Office or other outpatient visit for the evaluation and management of a new patient, the physician would need to document—at a minimum—a detailed history, a detailed examination and low-complexity MDM. Or, the physician may report 99203 if counseling and/or coordination of care comprise 50 percent or more of a visit lasting 30-44 minutes, and the content of the visit is properly documented.

Inpatient alternatives

You should report inpatient consultation services using an Initial Hospital Care code (99221-99223) for the initial evaluation, and a Subsequent Hospital Care code (99231-99233) for subsequent visits.

In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221). According to Centers for Medicare & Medicaid Services (CMS) guidance found in MLN Matters® Number: SE1010 Revised (“Questions and Answers on Reporting Physician Consultation Services”), you may report subsequent hospital care codes (99231-99233) in these cases:

Q. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?

A. There is not an exact match of the code descriptors of the low-level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an [evaluation and management (E/M)] service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and 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.

The same article assures providers that Medicare payors will pay for initial visits reported using subsequent care codes:

Q. How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?

A. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code 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.

Modifier AI distinguishes inpatient providers

When a Medicare patient is admitted, and another physician provides a consultation for that patient, the situation may arise in which both the admitting physician and consulting physician would report an initial inpatient service (e.g., 99221-99223). To differentiate between the two physicians’ services, and to prevent a claims denial for duplication of services, the admitting physician should append modifier AI Principal physician of record to the initial inpatient service code.

For example: A patient presents to the emergency department (ED) with chest pain. The ED physician evaluates the patient and codes an ED visit (99281-99285). He also requests a consult from a cardiologist. The cardiologist evaluates the patient and decides to admit him. The admitting cardiologist would report an initial hospital visit (99221-99223) with modifier AI appended.

If the patient also has uncontrolled diabetes, and the admitting physician (the cardiologist) requests a consult from an endocrinologist, the endocrinologist might also select an initial hospital visit code, depending on the level of service he provides, to report his consultation. But, the endocrinologist would not append modifier AI because he is not the admitting physician overseeing the patient’s overall care.

Per CMS guidelines, “In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.” For instance, if the cardiologist had not admitted the patient in the scenario above, she would have reported an ED visit because 99281-99285 are the best (non-consultation) codes to describe the service. For patients receiving hospital outpatient observation services who are not subsequently admitted to the hospital as inpatients, physicians should report 99217-99220, etc.

You can find complete guidelines with extensive coding examples in MLN Matters® Number: MM6740 Revised.

Save the date for AAPC’s HEALTHCON 2019, April 28 to May 1

AAPC, a training and credentialing association for the business side of health care, is hosting its 26th annual HEALTHCON on April 28 to May 1, 2019, in Las Vegas, Nevada. The conference is geared toward all levels of medical practice leadership and will offer attendees a multitude of tools and resources to help guide them to success, including:

  • Over 120 educational sessions featuring the industry’s hottest topics, including a presentation by Karen DeSalvo, M.D., President Obama’s Acting Assistant Secretary for Health.
  • 3,000 health care professionals to network with.
  • More than 75 exhibitors for a chance to learn about the latest products and services in the industry.

For more information or to register, click here.

AAPC has long been the California Medical Association’s (CMA) partner in billing and coding education, providing CMA’s monthly “Coding Corner” column and offering key education for the ICD-10 transition.


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