Intra-Office Consulting -- What You Dont Know Could Make You Money -- or Cost You An Audit
Published on Mon Feb 01, 1999
Executive Summary: In a large group practice, its quite common for a non-invasive cardiologist to request a consult from their interventional or electrophysiologist (EP) colleagues. Can every consult be coded 99251-99255 (initial inpatient consultation), instead of using the inpatient subsequent care codes (99231-99233)? If so, the specialty group could significantly increase its revenue. On the other hand, it could also risk the wrath of auditors. This article will carefully analyze this question as well as look at interpretations of the Health Care Finance Administrations (HCFA) payment policy.
Like many of our readers, Paula Harrison, coder at The Cardiovascular Specialists in Memphis, TN, wrote to ask us how to code for the consulting services within the same practice between subspecialists and general cardiologists.
Suppose one of our general cardiologists is following a hospitalized patient for unstable angina. But the patient develops arrhythmia, so the general cardiologist asks our EP for a consult. How do we charge for the subspecialists services? As a consult or a hospital inpatient code? she asks.
Cynthia Chu, RN, office manager of Cardiology Associates, Inc., in Honolulu, has a similar problem. She inquires, One of our four cardiologists has additional training in peripheral vascular disease. When one of our other cardiologists refers a patient to him for claudication/peripheral vascular disease, do we bill a 99244 (office or other outpatient consults) or 99215 (office or other outpatient visit)?
The answers to both questions depend on the interpretation of Item C in the Medicare Carriers Manual Section 15506: Consultations Requested by Members of Same Group.
The paragraph states: Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation code are met.
Tip: You can download this section from www.hcfa.gov. Go to Medicare, Professional/Technical Information, Medicare Professional/Technical publications, Medicare/Medicaid Manual, Download numbers 14, 15-1, 15-2, and 06.
So theres your proof. You can bill a consult by a subspecialist in addition to one by a general cardiologist within the same practice -- if the documentation for both supports the criteria of a consultation.
But thats a big if, warns Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC. The documentation of both requesting and consulting cardiologists have to meet the criteria. If it does, Medicare should pay for the consult, she stresses. But if the documentation doesnt meet the criteria, then you should not be billing it. The fact is that many consultations being billed are not true consults.
Thats why a thorough understanding of the criteria is vital. It will determine whether your practice can ethically increase its reimbursement [...]
