Cardiology Coding Alert

Question: We have four cardiologists in our group. Physician A is following a hospitalized patient for aortic stenosis. If he requests a consult from Physician B in our group for pulmonary edema, do we bill Physician Bs consultation as 99251-99255, initial inpatient consultation, or 99261- 99263, follow-up inpatient consultation?

Cynthia Chu, Cardiology Associates
Honolulu, HI

Answer: Use 99251-99255, initial inpatient consultation care.

Follow-up inpatient consultations, explains Thomas Kent, CMM, seminar leader for McVey and Associates, Nevada, CA, should rarely be used. For example, suppose Physician B performs the visit for the initial consult, does a history and physical, and then orders diagnostic tests, yet is not able to render advice based on that visit alone. So after the test results are in, Physician B returns to the hospital, performs another exam in order to complete the medical decision making portion of the evaluation. Then you can bill such a visit as a follow-up inpatient consultation.

If however, Physician B then took over the care of the patient for the pulmonary edema, you have to use subsequent hospital care codes. If both physicians continue to co-manage the patients condition, youd still use the subsequent hospital care codes for Physician Bs visits.

But be aware youre venturing onto the thin ice of concurrent care. Medicare generally considers it inappropriate and not medically necessary for more than one physician of the same specialty to bill for the same patient on the same day.

Medicare will only pay for concurrent care under certain conditions (i.e. if the patient has a multisystem disease or complications or if he or she requires both medical and surgical care).

So youll need to document the circumstances that warrant the expertise of the other physician with additional training and skills. Otherwise, Medicare will not consider concurrent care to be medically necessary. In that case, only the first physician to submit the claim will be paid, while the subsequent ones are denied. (Remember that Medicare will not determine which of several physicians is primary or attending.)

Thats why you must divide up the diagnoses, explains Kent. Physician A would code aortic stenosis and Physician B would code for pulmonary edema.

Even then you may have to appeal, he adds.