Real-World Coding Exposed: Increase Chances of Payment For Telephone Consultations

If you have a coding problem, we have an answer you may not find in your books. Sometimes your toughest coding scenarios can be answered only with real-world experience, and that's what will help you with consultation coding questions.
Problem: Our allergist was called as a consultant for an inpatient one evening. He spoke with the primary-care physician on the phone and spent a lot of time researching a particular diagnosis and possible treatments but did not actually see the patient until the next day to scope the patient.
Coding Solution: You could try using the CPT codes for telephone calls (99371-99373). These codes report "telephone calls by a physician to patient or for consultation or medical management with other health care professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists)." CPT defines a consultation as a "type of service 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 source."

Pay attention to what many coders call the consultation requirements, the "three R's": request, reason and response. Remember also to use the outpatient and inpatient service codes for consultations provided in the physician's office, an outpatient or other ambulatory facility, hospital, nursing facility or partial hospital setting. To assign a level of service, you must have three components, including history, examination and medical decision-making which require face-to-face contact with the patient.

If you use telephone call codes, you could run into a major problem. The Medicare Carriers Manual states that CMS will not pay for telephone calls because other billable services, such as the visit or surgery, include the payment for the telephone call work.

Many coders, however, recommend still coding for these calls to track and report all services provided.

But if your practice assigns any fee to these codes, the patient will be responsible to pay services not covered by the insurer, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Most physicians choose not to report these codes if they think their patients will be responsible for the payment.

Insurance companies do not like to pay for these codes because they assume they are used to represent time spent talking to patients.

Your only real option if carriers deny these claims is to call the provider representative and explain that the calls were spent discussing the case with another physician, not the patient. Try to negotiate with your payer to cover payment for telephone consultation calls as part of your contract.

You can use prolonged service codes to represent time (more than 30 minutes) spent on [...]

- Published on 2003-03-01