Avoid Upcoding or Downcoding:
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Published on Sat May 01, 1999
Although weve discussed coding for consults in the Emergency Department in previous issues, orthopedic consults continues to be a hot topic, both among orthopedists (who want to optimize reimbursement) as well as the Office of Inspector General (who has overcoding for this service on its hit list for 1999). Now, readers have asked us to determine when to code for consult or transfers of care when patients are admitted for fractures.
For example, a reader submitted this question: What is the proper E/M code to use when an orthopedist is asked to see a patient admitted with syncope who also sustained a wrist fracture during an episode? The orthopedist is first consulted for treatment on the care of the fracture but then assumed all care for that diagnosis.
Whether you code this type of service as a consult or transfer of care depends on whether you follow the CPT guidelines Section 15506 of the Medicare Carriers Manual (MCM).
They differ in that they do not agree on when a receiving physician can appropriately charge for an inpatient consult. For example, the CPT says the initial encounter can be billed as a consult even after transfer of care in the hospital setting:
If after a consultation is complete, the physician assumes responsibility for management of a portion or all of the patients condition, then he or she should use the appropriate inpatient hospital consultation code for the initial encounter and then subsequent hospital care codes (not follow-up codes).
Some sources, referring to the CPT guidelines, say that all initial encounters can be billed as inpatient consultations (99251 to 99255) with follow-up care billed as subsequent care (9923 to 99233). For example, Dawn Carpenter, CPC, billing manager at Ortho Associates of Grand Rapids, MI, says she probably would have used an inpatient consult code for the service in the syncope scenario. Our practice uses consultations primarily as we evaluate our patients and then make the decision to treat. In that case, we would bill the consultation with modifier -57 and then the fracture care service, she says.
However, a more conservative approach is typical of Todd Thomas, CPC, CCS-P, president of the Oklahoma Chapter of the American Academy of Procedural Coders. Thomas, who points out the definition of consults in the MCM, sees similar cases as a transfer of care, not a consult.
Most of the time when an orthopedist is called about an injury, he or she is not being asked by the requesting physician to provide opinions or advice on how that physician should care for the patient, but to actually take care of a fracture or dislocation, he explains. Therefore, even the initial encounter should not be billed as a consult.
Specialists often disagree because they cite [...]
