ED Coding and Reimbursement Alert

Question: A hospital attending physician needed our ED physician's opinion on an inpatient's condition, so the physician went to the patient's bedside and gave his assessment. How should we report this?

Codify Subscriber

Answer: When an ED physician is called to give his opinion outside of the ED, you may consider billing for an initial consult if all the requirements are met and if the insurer accepts consult codes. Before coding for a consult, remember the three requirements (previously dubbed the three R's): a request in writing in the medical record, a report that is written, and a return of care back to the initial provider.

Caution: Consultations are not appropriate as a matter of convenience when the attending service provider cannot see the patient due to other obligations. Encourage the ED provider to also document the name of the person who requested the consultation. It is important to know whether the patient's status is Inpatient or Observation, as this drives whether you choose Inpatient Place of Service (POS) 21 (CPT^® 99251-99255) or Outpatient POS 22 (CPT^® 99241-99245) consultation codes.

Note: Medicare does not recognize consultation codes. Instead, you'll more often report the appropriate inpatient or outpatient visit codes as appropriate. If the patient's condition is critical and greater than 30 minutes of time is documented, that may support Critical Care (CPT^®  99291-99292), and when total recorded time critical care, exclusive of separately billable procedures, meets the established thresholds. Otherwise, if the 30 minutes have not been met, you may be able to charge subsequent hospital care (99231-99233).