Internal Medicine Coding Alert

Published on Thu Sep 11, 2008 PDF

Your internist usually provides pre-, post-op consults

Coders who don't want their consult claims cancelled should take a second and check out these expert opinions on when to code a consult -- and when to choose another reporting option.

"A consultation is basically a request for opinion or advice, because the requestor does not have expert knowledge in that area," explains Denae Merrill, CPC-E/M, owner of Merrill Medical Management in Michigan.

But it can be a bear sticking to all of the consult reporting rules, as your coding will vary based on location and service level. Read on for more information on coding -- and documenting -- your consultations correctly each time.

If a physician is treating a patient and needs to ask for an internist's input on treating that patient for a certain condition, you might consider it a consultation. Your internist will most often provide the consultation in an office setting, which you code with 99241-99245 (Office consultation for a new or established patient, which requires these three key components ...), depending on the level of service.

Note: CMS guidelines require a physician or qualified nonphysician practitioner (NPP) to make the request for a consult. CPT states that the request can be from a physician or other appropriate source. So be wary of individual payer policies before you file a request for consultation. (Remember: Medicare limits the definition for the NPP provider category to the following: a nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse midwife).

Most of your internist's consultations will be for patients undergoing surgery, either before or after the procedure. The patient will likely have a chronic medical condition, Merrill says, and the consult is designed to answer the question: "Can this patient go through with the surgery?"

Example: A 68-year-old patient with uncontrolled type II diabetes is about to undergo a major surgical procedure. Before the operation, the surgeon requests that the internist check the patient for any conditions that might not make him a good candidate for surgery. The internist performs a level-two office consult service and deems the patient fit for surgery. The internist sends the surgeon a report, along with a tally of treatments rendered.

This is a pre-op consultation. On the claim, report 99242 (... an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision making) for the consult, with 250.02 (Diabetes mellitus; type II or unspecified type, uncontrolled) appended to represent the patient's diabetes.

The most common pre-op inpatient consult occurs when a specialist admits the patient for surgery, but the patient has a comorbid condition that requires surgical clearance (as in the above example). In these cases, "the specialist requests a consult for the internist's opinion of the stability of the patient for surgery," says Pat Strubberg, CPC, coder at Patients First Health Care in Washington, Mo.

"But if a patient comes in for a routine checkup prior to surgery and has few to no chronic conditions, it is highly unlikely to satisfy the consultation requirements," she says. Code these services with a standard office E/M (99201-99215).

There are also codes for consults the internist performs for hospital inpatients. When the internist performs an inpatient consultation, code it with 99251-99255 (Inpatient consultation for a new or established patient, which requires these three key components ...), depending on the level of service, confirms Strubberg.

Inpatient consults can be pre- or post-operative, depending on the situation. If a patient's chronic condition is exacerbated by the surgery or a possible new condition emerges following surgery, your internist might perform a post-op consult, Merrill says.

A provider who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code "when all of the criteria for the use of the consultation codes are met, and that same physician has not already performed a preoperative consultation," according to Chapter 12, Section 30.6.10 of the Medicare Claims Processing Manual.
(Note: In the office, use the appropriate E/M codes for visits during the post-op period that do not meet consult requirements.)

"There needs to be appropriate documentation to support the use of the [inpatient] consultation codes. Make sure an opinion or advice on a specific matter is being sought, and the service is not a general routine post-op medical management," Merrill says.

In the hospital, the provider who performs a pre-op consult and assumes responsibility for some or all of the patient's conditions during the post-op period "should use the appropriate subsequent hospital care codes to bill for the concurrent care he provides," states CMS.

When you submit a consult claim, you should also include documentation that explains the consultation circumstances. Documentation requirements for consults will vary by payer, Merrill offers.

But Strubberg says that your consult documentation should at least include:

• a written or verbal request for the consult

• the consultant's (internist's) opinion

• any services the consultant provides or orders

• a written report to the requesting physician or provider.