Orthopedic Coding Alert

Orthopedic coders are still confused about when its appropriate to bill for initial inpatient consults (99251-99255).

For example, a coder from Minneapolis writes, We are getting conflicting or impossible directions. We have been told that we cannot code for an inpatient consult if we order tests or perform a procedure, yet we are also told that only one physician can code for attending physician care (99221-99223). So, when a patient breaks a hip and is admitted by the primary physician and we are asked to see the patient for orthopedic care and surgery, can we code for a consult if we plan to operate?

The short answer is no if the patient is a Medicare beneficiary and perhaps if he or she is not.

The long answerand the one coders need to thoroughly understand in order to stay out of trouble with the Office of the Inspector General (OIG)is that CPT and the Medicare Carriers Manual (MCM) differ on the conditions under which specialists can bill a consult, explains Steve Arter, executive vice president in the compliance and education division for QuadraMed Corporation, a healthcare services company in Point Richmond, CA.

This disagreement is more than semantics, however. If you go by the CPTs definition in billing for Medicare patients, you could be setting yourself up for overpayment, he warns. Thus, you could be found liable during an audit and be required to refund some money, plus fines and interest.

The CPT manual states the initial encounter can be billed as a consult even after assuming management of all or a portion of the patients care (i.e., orthopedic surgery). The logic is that the specialist must first see and evaluate the patient before he or she knows how to treat; therefore, the service is a consultation.

Most of the orthopedic coders we spoke to coded according to CPT. They considered the initial encounter for the hip fracture as an initial inpatient consult (99251-99255) and appended a -57 modifier to show that decision for surgery was made at that encounter.

However, those who insist on coding this way for Medicare patients are on dangerous ground, Arter maintains.

Section 15506 of the MCM says that if transfer of care takes place at the initial encounter, an inpatient consult cannot be billed. Instead, use subsequent hospital care codes (99231-99233), appended by a -57 modifier (decision for surgery).

The Health Care Financing Administrations (HCFA) interpretation hinges on the intent of the requesting physician: If the primary care physician calls the orthopedist to fix a problem that is beyond his or her capability, then HCFA regards the request as a transfer of care.

For example, if an x-ray showed a severe fracture, then the primary care physician would know in advance [...]