Internal Medicine Coding Alert

Question: Our internist was asked to do a pre-operative evaluation of a patient with hypertension before she had surgery for an unrelated gynecological condition. While she was recovering in the hospital, her gynecologist determined that her hypertension had gotten worse and asked the internist to assume responsibility for that portion of care. The internist believes that his postoperative evaluation and management (E/M) visits with this patient should be billed as followup consultations (99261-99263) because he billed the initial preoperative evaluation of the patient as a consultation. I disagree and feel that a consultation should not be billed because the gynecologist has transferred care of the patient to the internist. Whos right?

West Virginia Subscriber

Answer: Neither you nor your internist is reporting this properly. Not only is your internist incorrectly reporting these postoperative visits, he or she is also losing reimbursement dollars because of insistently billing a followup code instead of the more appropriate subsequent hospital care codes (99231-99233).

Both the CPT manual and the Medicare Carriers Manual (MCM) advise that an internist who assumes management of a portion or all of the patients conditions after the completion of a consultation should not use the followup consultation codes. The CPT manual states that, in the hospital setting, the consulting physician should use the appropriate inpatient hospital consultation code for the initial encounter and then subsequent hospital care codes (not followup consultation codes).

Section 15506(F) of the MCM specifically addresses your preoperative/post-operative situation: The physician who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patients condition(s) during the postoperative period should use the appropriate subsequent hospital care codes (not followup consultation codes) to bill for the concurrent care he or she is providing.

Because office consultations (99241-99245) have higher reimbursement than a comparable office visit, most internists seem to believe that a followup consultation will have higher reimbursement than a subsequent hospital care visit, which is not true. A level-two followup consultation (99262) has a transitioned, facility relative value unit (RVU) of 1.28 versus a level-two subsequent hospital care visit (99232), which has an RVU of 1.50.

A more appropriate use of the followup consultation codes would be to complete an initial consultation with a patient, according to Stephanie Jones, CPC, a multispecialty coding consultant in Boca Raton, Fla. These codes were designed for when an internist is asked to come in for an opinion, she says. The internist takes a history, does a physical examination and some medical decision-making such as ordering a test but cant render an opinion until the results of the test are back.

Jones also cautions that the followup consultation cannot be reported on the same day as the initial consultation. Usually only one E/M code can be billed per day for a particular patient by a internist, she explains. If the internist sees the patient in the morning and sees him in the afternoon of the same day after some test results come back, you can't report the followup consultation. It has to be on a different day.