Internal Medicine Coding Alert

Get the most of out of 99241-99245

With the HHS Office of Inspector General targeting consults in its 2004 Work Plan, you should ensure that you document all steps in consultation coding and properly report preoperative clearances. Here's how:

1. Know That Payers Vary on Guidelines

Medicare and private payers may differ on who can request a consultation. Medicare states that only a physician, nurse practitioner, physician assistant or certified nurse midwife may request a consultation. In other words, social workers, physical therapists and nurses can't legitimately request consultations for Medicare patients and expect payment, says Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H.
 
CPT definition, which some third-party payers follow, lists the same medical staff as qualified to request consultations as Medicare but also includes another "appropriate source." An "appropriate source" includes physical therapists, occupational therapists, speech therapists, psychologists, social workers and even lawyers, Nicoletti says.

2. Follow the Three R's of Consultation Reporting

Learn what to look for in the documentation so you  don't confuse office visits and consults. The documentation provides one of the main distinctions between a consultation and an office visit, Nicoletti says.
 
When you report a consult, you must ensure that the documentation shows a reason, a rendering of opinion, and a report, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a national healthcare consulting firm in Lansdale, Pa.
 
Reason: The physician must formally request a consultation from your internist, which is the reason your internist consults with the patient. Your internist must document the need for a consultation in the patient's medical record. For example, a patient presents to his or her endocrinologist with abnormally high blood pressure (401.9).The endocrinologist requests that the internist examine the patient and provide a diagnosis. The internist also documents the request in the medical notes.
 
Render: Your physician should document what he or she suspects as the patient's condition. A consultation always involves a suspected problem and an unknown course of treatment.
 
Furthermore, the internist should document the visit's medical necessity (high blood pressure). After your internist examines the patient, he diagnoses the problem as diabetes (250.xx) and advises the requesting physician on a course of action.
 
Report: Now the internist should prepare a written report based on his or her findings, and provide the requesting physician the report, Nicoletti says. Typically, the physician includes the suggested treatment plan in the last paragraph. The report also provides an opportunity for the internist to document the requesting physician's request.

3. Rarely Use 99245 for Preoperative Clearances

When you bill for preoperative consults, remember that the level of care dictates what code you use. Even so, for preoperative consultations, you will probably use 99242 or 99243.
 
Rarely does a physician clear a patient for surgery following a 99245 preoperative consultation, because the physician would determine the patient condition too unstable for surgery.
 
To use 99245, for instance, your internist would have to determine that the patient's hypertension was out of control, which would meet the requirements for high-complexity decision-making.
 
But after your physician developed a treatment plan to control the hypertension, he or she approved the patient for the hip replacement.
 
Also, you should know which ICD-9 codes to use and the correct order for listing them.
 
Suppose an orthopedic surgeon sent a patient with  hypertension (401.x) and chronic bronchitis (491.x) to your internist for a preoperative evaluation and clearance. Your internist's documentation supports 99242. In that case, the documentation should show an expanded problem-focused history and exam, and straightforward medical decision-making that took your internist about 30 minutes to perform.