# Can this consult be coded?



## Trendale (May 8, 2009)

Please let me know if I am able to code at least a level 1 consult from the following dictation:

Reason for consultation: code 90
Assessment: I was in the intensive care unit. The patient had arrived from PCU. He went into sudden ventricular tachycardia and lost pulse and blood pressure. I responded along with the nurses and code 90 was called. A defribrillator pad was placed on the patient immediately, and immediately he was defibrillated with 200 joules. He returned to a sinus rhythum with subsequent palpable pulse and blood pressure at that point. He was initially unresponsive but became responsive within 1 minute. Patient had repeated runs of ventricular tachycardia, nonsustained thereafter, for which he was subsequently bolused with IV amiodarone and will be placed on amiodarone infusion and after discussion with cardiology.


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## cheermom68 (May 8, 2009)

*consult*

This does not qualify for a consult.  It sounds like critical care to me.


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## FTessaBartels (May 8, 2009)

*92960*

I get only 92960 - Cardioversion

You can't code critical care because there is no time (must be 30 minutes or more EXCLUSIVE of procedure  - cardioversion in this case). 

There is no request for a consult. I could be convinced to also code 99231 (with -25 modifier) ... you have high risk, but I can't tell if this is a new problem or an existing problem (for problem points); there are no data points. 
You have a PF interval history and a PF exam (by 1995 guidelines). 

F Tessa Bartels, CPC, CEMC


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## cheermom68 (May 11, 2009)

*consult*

I agree that you need the time.  I was just looking at the category of care to give a suggestion of what to look under.  Sorry for the confusion.


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## Karolina (May 11, 2009)

*Not a consult*

The defining criteria of a consult is that another provider asks for the expert opinion of your provider. I am not sure that was the case in your example. Then the documentation must identify the requesting provider, the recommendation given and of course, it must be reported back to the requesting. None of those conditions are met in your scenario, so it cannot be a consult.


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## Trendale (May 12, 2009)

*Reply back from original poster*

I agree that it should not be a consult as well. So I am left with the 92960 ( cardioversion) and the 99231 (Subsequent). I am leaning more toward using the 92960 because the description of this code is exactly what he stated. This would have been an initial visit, so I don't believe the F/U would be appropriate, but I could be wrong. So what do everyone think is the most appropriate out of the two? Is there any criteria on  using the 92960?


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## FTessaBartels (May 12, 2009)

*Subsequent hospital care*

ANY physician who sees the patient after the admitting physician can code the subsequent hospital visit CPT 99231-99233 (assuming s/he's not providing an inpatient consultation).

Your documentation does perfectly describe the 92960, which is why I suggested it. 

I really *do not *think you have a significant, separately reportable E/M besides the cardioversion, but I'd be willing to listen to opinions that argue you do. 

F Tessa Bartels, CPC, CEMC


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## Karolina (May 13, 2009)

I agree with Tessa - there is no significant, separately identifiable E/M service documented. You cannot bill for the subsequent care in this scenario. If there is more information than what you supplied, then I would reconsider, based on the additional documentation.


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## twosmek (May 13, 2009)

*Consult coding*

My office is in an uproar as well, We are an orthopedic specialty clinic. Most if not all of our new pt are referral from a PCP in our hospital system. We have the request for a referral/consult depending on the MD whether it is in the visit dictated note or in an official request. The ortho MD does send a copy of thier visit to the referring MN and most time assumes the care of that problem. I am also now asking what the intent is from the PCP and get Eval & treat almost everytime. I will list some scenerios and please help me decided which ones should be consults and which ones New pt/est pt.

#1 PCP sees pt for annual physical, pt states that they have had knee pain for 2 yrs. PCP tells the pt that they should be seen by orthopedics and sets up the appt. The pt is seen here xrays are ordered and viewed. Orthopedic MD decides that a MRI is needed and schedules the MRI and an appt for the pt to come back to review the result. A copy of the dictated note is CCed to the PCP.
Consult or New/Est Pt

#2 PCP has been seeing pt for shoulder pain for 6 months has had MRI and xrays taken. PCP decides that there is nothing more he can do and tells pt to see an orthopedic MD. Sends a request to orthopedics to schedule an appt. Pt is seen and it is determined that she needs an arthroscopy, surgery is scheduled and pt will f/u with orthopedic MD. Orthopedic CC's PCP on note.
Consult or New/Est Pt

#3 PCP decided that pt needs a steroid injection into a shoulder joint. PCP sends referal to orthopedic MD for injection. Orthopedic MD has xrays taken and then does an injection and tells pt to follow up in 2 weeks with orthopedics. Orthopedic MD sends copy of note to PCP.
Consult or New/Est Pt

#4 PCP sees pt for shoulder pain, has already had xrays and MRI ordered by PCP. PCP determines the PT needs a rotator cuff repair, tells pt he needs to have an orthopedic MD do the surgery. PCP sends referral to Orthopedic to evaluate for rotator cuff repair. Orthopedic MD sees patient and does schedule Rotator cuff repair and pt will follow up with Orthopedic MN. CCs note to PCP.
Consult or New/Est PT.

Thoughts??


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## Karolina (May 13, 2009)

*Answers for twosmek*

A consult requires the 3 R's - Request, Recommendation, Report back - and I'm sure you already know that, just had to reiterate.

If the requesting MD - in your scenarios the PCP - asks your provider for an expert opinion and intends to continue caring for the patient him-/herself that would be a consult (even if your doctor does workup, and even if at the end of the visit the decision is made that the patient will be cared for by your doctor for the ortho problem).
On the other hand, if the PCP (or any other referring provider) sends the patient to your specialist with the intent that your MD continues caring for the patient (e.g., for that particular issue) then it is a transfer of care; the PCP is not looking for advice on how to deal with the issue at hand.
In your cases I would say:

#1: Not a consult - this seems to be a referral for treatment. It does not look like the patient is seen and worked up so that the PCP will get feedback on what to do about the problem. However, it is rather borderline and if the request for opinion is documented clearly I would reconsider.

#2: Not a consult - this is very clearly a transfer of care.

#3: Not a consult - the patient is definitely sent for treatment, not for an opinion; the PCP already decided on the treatment and is sending the patient to the specialist to get it done.

#4: Not a consult - again the PCP decided on treatment and sends the patient to the specialist to get it done. If the PCP were to consider surgery and to be sure ask the specialist for an opinion if this would be the appropriate course of action, then I would consider the consult.

This is my opinion. Hope it is helpful!
Karolina, CPC


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## twosmek (May 13, 2009)

Yes that is very helpful, as I am looking for opinions to bring to my MD and my manager to prove my point thank you


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