Gastroenterology Coding Alert

Question: One of our physicians was asked to consult on a patient who was in a nursing care facility that operates out of a nearby hospital. We reported 99244 with a place of service of 32. Medicare denied the claim, stating that the place of service and CPT code did not match. How should we have coded this service?

Arkansas Subscriber

Answer: The carrier is correct - the CPT code and place of service do not match.
 CPT specifically notes that office or other outpatient consultation codes 99241-99245, including 99244 (Office consultation for a new or established patient ...), "are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department." Place-of-service indicator 32, in contrast, denotes an inpatient facility (specifically, a nursing facility) as the site of care.
 
Initial inpatient consult codes 99251-99255 "are used to report physician consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting," according to CPT, and are appropriate with a 32 place-of service-indicator. Assuming your documentation supports a level-four consult, the correct code in this case is 99254 (Initial inpatient consultation for a new or established patient ...). Similarly, report any subsequent inpatient nursing facility care with the same patient using subsequent hospital care codes 99231-99233 and any follow-up consultations using codes 99261-99263.