Internal Medicine Coding Alert

Answer: Generally, when a physician provides a hospital consultation regarding a patient's condition, you can use the initial inpatient consultation codes (99251-99255) only once for that physician (or any other physician from the same group, with the same specialty, who sees the patient for the same reason) during that hospital stay. Use the follow-up inpatient consultation codes (99261-99263) for any subsequent consultations provided by the physician during the patient's stay or when the initial consultation requires more than one day to complete. If the consulting physician assumes any portion of the patient's care after the initial consultation, you should use the subsequent hospital care codes (99231-99233) for the follow-up visits.

The subscriber's question raises several issues. Once the patient was admitted under the physiatrist's service to the rehabilitation unit, often referred to as a "swing bed unit," a "new" patient stay began. The facility bills these "swing bed units" as skilled nursing facility (SNF) care, separating the patient's stay in the hospital from her stay in the rehabilitation unit. The hospital actually discharges the patient and then readmits her to the SNF, but the patient never physically goes to a new facility, just a different floor.

So, yes, the patient began a new stay when she moved to the SNF, and your service could qualify as an "initial" consultation on that basis. But that is not the only factor in determining whether you should charge a new consultation for care provided to the patient after she moved to the SNF. Whether you can depends on the service that you provided. Ask yourself if it meets the definition of a consultation: "A request from another physician for your advice or opinion regarding evaluation and/or management of a specific problem." If you answer yes, then you can bill using the 99251-99255 series.

However, your carrier may not consider the 99254 level of service "medically necessary" if you have been following the patient for the previous six days. Code 99254 requires a comprehensive history (which includes an extended history of present illness, a complete review of systems, and a complete past, family and social history), as well as a comprehensive medical exam. You will have to evaluate whether you can show medical necessity for using this code.

The patient's return to the neurosurgery unit in the hospital constituted a new admission, regardless of the fact that you provided a consultation to her on the previous day. You provided services in different settings the SNF (rehab unit) and the hospital. So as the admitting physician, you can bill an admission code (99221-99223, Initial hospital care). Select this code based on the work you did on the day of the patient's admission to the hospital.

The admitting physician can use the admission codes once during a patient's stay regardless of whether it is a new patient or when the physician last saw the patient.