# Outpatient Consultation code 99204/ Observation status 10 days later



## loyalty (Dec 29, 2010)

Patient was seen as a new patient in the office and was coded 99204

10 days later, Patient was in observation status on day 1 and discharged on day 2. What is the proper consultation code to use for the  physician consultation done on day 2 by the same physician that seen the patient 10 days prior?


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## btadlock1 (Dec 29, 2010)

CPCljohnson said:


> Patient was seen as a new patient in the office and was coded 99204
> 
> 10 days later, Patient was in observation status on day 1 and discharged on day 2. What is the proper consultation code to use for the  physician consultation done on day 2 by the same physician that seen the patient 10 days prior?



Let me see if I can answer this correctly...

Your doctor seeing the patient 10 days earlier may or may not be significant. If he has taken over as the managing MD for the condition he consulted on, then he should bill an outpatient/office established E/M code, as it is not technically a consultation. If he is not managing the care for that condition, and his *professional opinion ONLY *was sought by the doctor in charge of observation, then he should report an outpatient consult code. 

For example, if the patient is diabetic and sees your doctor specifically for management of their diabetes, but is admitted to observation for CAD, it is feasible that the observing physician might request a consultation to get your doctor's opinion on the status of the CAD, because the patient's cardiologist is out of town. That's an outpatient consult.

Now, let's say your doctor has taken over as the patient's primary care physician, and manages both their diabetes and CAD. If the patient is admitted by another physician for observation of the CAD and your doctor evaluates them at the other physician's request, (or at anyone else's request, for that matter), it's an outpatient/office E/M for an established patient.

Am I close?


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## loyalty (Jan 3, 2011)

Yes. Brandi, this was  very helpful.


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## Lizz B (Jan 5, 2011)

*place of service*

Brandi, can you take this one step further?  If the patient is admitted to observation from the ER and my physician is called in to see the patient while she/he is still in the ER, what is the correct place of service? I would think it would be 23 for ER, but then what would be the correct E/M code? If the patient is new to my physician I would use a 9920x for NP OP code, correct?
If the patient is moved from ER to the floor but still is observation and not designated as IP, do I then use 22 as POS?
I'm having a lot of trouble with this.  I have a ton of claims denied for no auth for observation patients seen for hospital consults.  I'm sure the hospital is billing POS since a claims rep suggested that is the correct pos, but my supervisor is telling me this should be 22 because the patient was discharged from the ER to observation.  But if my physician is called to the ER and sees the patient there, he would have no way of knowing the pt is observation.
Please help!


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## btadlock1 (Jan 6, 2011)

Lizz B said:


> Brandi, can you take this one step further?  If the patient is admitted to observation from the ER and my physician is called in to see the patient while she/he is still in the ER, what is the correct place of service? I would think it would be 23 for ER, but then what would be the correct E/M code? If the patient is new to my physician I would use a 9920x for NP OP code, correct?
> If the patient is moved from ER to the floor but still is observation and not designated as IP, do I then use 22 as POS?
> I'm having a lot of trouble with this.  I have a ton of claims denied for no auth for observation patients seen for hospital consults.  I'm sure the hospital is billing POS since a claims rep suggested that is the correct pos, but my supervisor is telling me this should be 22 because the patient was discharged from the ER to observation.  But if my physician is called to the ER and sees the patient there, he would have no way of knowing the pt is observation.
> Please help!



It depends on where the E/M actually takes place - if they've already been moved out of the ER by the time the doctor sees them, then it's not going to be the ER. For observation status, I believe the POS is outpatient hospital, but I'm not certain - I don't have my CPT with me, either.  
Here's what I found online, though: (http://www.medicarepaymentandreimbursement.com/2010/09/initial-hospital-observation-care.html)

_When a physician decides to place a patient in â€œhospital observationâ€� status, that patient has not formally been admitted to that hospital. The physician who placed the patient in â€œhospital observation,â€� is the only one who may care for the patient during his/her stay in observation, and the only one that may bill the hospital observation codes.

In order to bill the initial observation care codes, 99218 through 99220, the following must be created and maintained:
 •A medical observation record for the patient which contains dated and timed physician's admitting orders regarding the care the patient is to receive while in observation;
 •Nursing notes; and
 •Progress notes prepared by the physician while the patient was in observation status.
 If applicable, this record is in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

When payment is made for an initial observation care code, it is for all the care rendered by the physician on the date the patient was placed in observation. All other physicians who see the patient in observation must bill the outpatient/office visit codes, or outpatient consultation codes, for the services they provide to that patient.

For example, if an internist admits a patient to observation and asks an allergist for a consultation on the patient's condition, only the internist may bill the initial observation care code. The allergist must bill using the outpatient consultation code that best represents the services provided. The allergist cannot bill an inpatient consultation because the patient was not admitted as a hospital inpatient. _

Supercoder.com has this to say (it's using a cardiologist as an example): (http://www.supercoder.com/articles/articles-alerts/cca/reader-question-emergency-department-coding/)

_•The patient is not registered at the ED, even though he or she met the cardiologist there. In such cases, an outpatient visit code should be reported, with 23 (for ED) listed as the place of service.

Although the guidelines are clear, many carriers, private and Medicare alike, continue to accept only one ED bill per patient per day, regardless of how many physicians see the patient in the emergency room. An ED visit that cannot be coded as a consultation, admission/observation or critical care service should be reported using outpatient visit codes, listing 23 (for ED) as place of service.

Often, the cardiologist's ED encounter may be correctly billed as a consultation. Some cardiologists, however, routinely bill consults when they see a patient in the ED. This is incorrect, Fletcher says, noting that according to the MCM, â€œIf the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are metâ€� [emphasis added].

The three criteria for a consultation are stated in the MCM, section 15506:

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate choice.

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.

3. After the consultation, the consulting physician prepares a written report of findings that is provided to the referring physician.


If the documentation does not indicate that these criteria have been met, the consult may be denied.

If the cardiologist sees the patient in the ED and then admits the patient to the hospital on the same calendar date, only an admission code (99221-99223) can be billed, according to the MCM. All E/M services provided by the cardiologist are considered part of the initial hospital care when performed on the same date as the admission._

Hope that helps!


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## Lizz B (Jan 8, 2011)

Brandi, thank you for quick, concise reply.  I believe our office may be billing some of these incorrectly using POS 22 rather than 23.  I'll have to discuss this more in depth with my supervisor.


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## btadlock1 (Jan 8, 2011)

Lizz B said:


> Brandi, thank you for quick, concise reply.  I believe our office may be billing some of these incorrectly using POS 22 rather than 23.  I'll have to discuss this more in depth with my supervisor.



Anytime! If I were in your shoes, I'd take printouts like the example I gave you, but from the actual website, to back up your case. It always helps to have an authoritative opinion that proves you're right, when you're about to criticize the status quo. Trust me on that.


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## jmwallen (Feb 6, 2013)

*Julie*

Hi Brandi, 

Can you help me with a problem I am having with consultation charges?

I am coding for a Urologist and he does alot of consults. He says he does not have to mention the referring physician in his progress note (HPI). I think that is a requirement. He says as long as he has the referring physicians name mentioned in the electronic record and a faxed record of the note being sent back to the referring that is ok. 

Is this ok?  

We always went by the 3 R's--- Request,Render an opinion and Report information.

Thanks
Julie


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## btadlock1 (Feb 6, 2013)

jmwallen said:


> Hi Brandi,
> 
> Can you help me with a problem I am having with consultation charges?
> 
> ...



The guidelines state that "The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or other appropriate source. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record, and communicated by written report to the requesting physician or other qualified source."

So, technically, he doesn't have to mention the requesting doctor in his notes, as long as he has a record of rendering a written report, detailing all of the services he ordered and provided, as well as his opinion, and sends it back. But, I wouldn't advise him to rely on the referring physician to document the request for the consult, if I were in his shoes - after all, HE is the one getting paid for the consult, so he'll be the one to lose money, if the other doctor fails to make a note in the patient's record, reflecting the consult request. It would be worth the effort to be cautious, and add the words 'for a consultation requested by Dr. John Doe', to his HPI notes. Just my opinion, though. Hope that helps!


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