# When criteria is not met for a consult?



## AmandaW (Oct 8, 2014)

Regarding the commercial insurances that DO still take consult codes, what if the "consult" visit does not meet the "3 R's" ?  I have doctors that will have consult on the record but doesn't meet any of the criteria. Would you default to a 99221-99223?  Or a subsequent visit 99231-99233?


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## mitchellde (Oct 8, 2014)

You would have to bill a subsequent encounter level


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## AmandaW (Oct 8, 2014)

Thanks Debra!

Just wanted to make double sure and clarify that although they don't meet the 3 R's necessarily, they DO meet the guidelines as far as documentation goes for a 99221-99223.  They'll have enough HPI elements, history, MDM, etc. to meet the Admit code 99221-99223....just not the consult criteria.  

Would still do the subsequent codes?


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## mitchellde (Oct 8, 2014)

I am confused.... If you have the criteria for a 99221 then you have more than enough for a low level inpatient consult code.  If you have a payer that will pay consults you bill the consult.  If you have a payer like Medicare that does not recognize consult services you bill with the initial inpatient levels.  If they have not met consult criteria with the 3Rs then yes use subsequent levels.


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## Partha45 (Oct 9, 2014)

If not yet meet consult criteria we need to code Subsequent hospital visit code (99231 -99233)]


Parthasarathi P CPC


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## AmandaW (Oct 9, 2014)

Debra, they'll have "Consult" as the heading but sometimes won't have the consult criteria such as the Request, Render, and Respond.  I need to educate them further on "Consults" b/c I don't think they're doing true consults but in the mean time not sure what to do with the current notes. 
Their notes often don't really reflect that an "opinion" is being asked.  
I think I need to just stop, not bill anything and have them append the note. 

But I have guidelines that says "A consult should only be billed if the requirements are met. Remember the "3 Rs" of a consultation."

So, I know if the guidelines aren't met for a 99221-99223, you CAN drop down to a subsequent visit. So, wasn't sure what exactly to do if documentation guidelines were met, but the "3 R's" were not....?


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## AmandaW (Oct 9, 2014)

Debra, I re-read what you said and noticed you answered all that in your last sentence.  Uhh long day.  

Thank you!


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