Internal Medicine Coding Alert

Tip: You should be able to distinguish between the four types of visits

You can ensure payment and prevent Medicare scrutiny of your consultation claims if you know two things: how to code the correct service level, and  Medicare's documentation requirements.

Spot Consultation Documentation

Before you can use consultation codes (99241-99275) with confidence, you should understand how a consult differs from a regular office visit, coding experts say.
 
Generally, a consultation means a physician, other healthcare practitioner, patient or other third-party has requested that your internist render advice on a specific problem (such as diagnosing a condition), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
 
On the other hand, an office or inpatient visit involves ongoing care of the patient, according to CMS guidelines.
 
Consultation example: A surgeon requests your internist's opinion on whether a patient with diabetes (250.xx) and hypertension (401.x) is fit for surgery. Depending on location and documentation, you could report the appropriate consult code 99241-99275.
 
3 Easy Ways to Support Consultations

Because Medicare has received so many incorrectly coded consultations, you may think reporting these visits with accuracy is a daunting task. But you can code consults with ease if you remember the three R's:
 
Request: Another physician, provider, patient or private insurer has to request your internist's advice or opinion. Your physician can document this request in his report back to the referring physician, Pohlig says.
 
Render: The internist has actually evaluated the patient and developed a plan of care, Pohlig says. Example: If during the consult your internist determines that a patient has depression (311, Depressive disorder, not elsewhere classified), he should document this diagnosis.
 
Report: Your internist provides the requesting physician a report of his opinion or advice, Pohlig says. In the report, your physician should include the request, his opinion and a treatment plan.

How to Code 4 Different Consultations

CPT didn't create all consultation codes equally - so you shouldn't code your physician's consults the same way. Here's how to code the four kinds of consultations:

1. Office or other outpatient consultations (99241-99245)

You should report 99241-99245 when the internist provides a consultation in the office or other ambulatory facility, such as the patient's residence, a hospital observation unit, or an emergency department.
 
Example: During a woman's annual physical, her ob-gyn notes that she has elevated blood pressure (401.9, Essential hypertension; unspecified). Because the patient has a family history of hypertension and heart disease, the physician sends her to your internist for an evaluation. Your internist finds that the patient's blood pressure is elevated but does not require medication. So, he gives the patient a "heart healthy" diet plan to follow. Your internist reports his opinion and asks the ob-gyn to monitor the patient's blood pressure.

2. Initial inpatient consultations (99251-99255)

The internist provides these in an inpatient hospital, skilled nursing facility, or partial hospital setting. You can report 99251-99255 only once per inpatient admission.
 
Example: One of your internist's patients enters a hospital with congestive heart failure (CHF), and also has multiple co-morbidities, such as diabetes (250.xx). Your internist calls in an endocrinologist to render an opinion and offer advice on controlling the patient's diabetes. The endocrinologist evaluates the patient and recommends how to control the diabetes.

3. Follow-up inpatient consultations (99261-99263)

Use these codes when your internist completes an initial inpatient consultation or provides a new consultation after he's already performed an initial inpatient consultation during the single admission.
 
Coding tip: You should not report 99261-99263 for any subsequent hospital visits the consulting physician provides, says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise. If the consulting physician manages the patient's care following the initial inpatient consultation, you should use the appropriate subsequent hospital care code 99231-99233, he adds.
 
Example: Using the endocrinologist's advice, your internist controls the hospitalized patient's diabetes. Five days later, the patient's blood sugar level spikes again, so your physician calls the endocrinologist in for a second consultation. Because the guidelines only allow one consultation per admission, the endocrinologist will now use the follow-up consultation codes for the second visit.

4. Confirmatory (or second opinion) consultations (99271-99275)

Patients often request these to get a second opinion to another physician's diagnosis. Also, third-party insurers may request them before they approve a medical treatment or surgical procedure. You can report 99271-99275 for both inpatient and outpatient confirmatory consults.
 
Example: A 60-year-old woman with hypertension, hyperlipidemia (272.x, Disorders of lipoid metabolism) and diabetes is taking multiple medications and has significant menopausal problems. Because of this problem and her family history of coronary artery disease, an internist recommends not to initiate hormone replacement therapy. The patient presents to your internist for a second opinion, which he provides in a report to the treating physician.