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 that he or she would not perform the required surgery. Hence, as HCFA sees it, the orthopedist is being called to treat, not to render an opinion.

On the other hand, if the primary physician is calling the orthopedist for adviceTell me how I can manage this patientthen Medicare does not regard that as a transfer of care. Thus, this initial service can be billed as a consult. (See specific examples of consulting in the next column.)

To help you decide whether to bill a consult or subsequent care code, read the documentation carefully. If the report says Patient referred by ..., watch out. The word referred may be interpreted by a payer as transfer of care. Therefore, if you bill as a consult, it could be considered that you would be upcoding.

Needless to say, this interpretation of HCFAs guidelines for coding a consult for the initial encounter is causing a difference of opinion between providers and third-party payers. Many local carriers are confirming this interpretation with their regional office. Check with your local carrier representative before you automatically continue to bill initial encounters as consults.

Note: You do receive more reimbursement when you bill consults. For example, at the highest level of service, the difference between an inpatient consult and subsequent hospital care is $106, and the difference between an office consultation and an office visit is $75. However, if you fall outside HCFAs bell curve for the E/M services, you could be subject to a post-payment review. Auditors are allowed to go back seven years and pull a random chart sampling. If youve been overpaid on consults 20 percent of the time, then HCFA will use that figure to extrapolate back pay on all consults billed for the last seven years. Plus, theyll charge interest.

Can I Code a Consult?

Concerned about whether a consult is justified under HCFA regulations, ORC readers submitted actual patient encounter documentation, which we have paraphrased below, and our experts advise them on how to code.

Case 1: A 91-year-old woman, who suffers from dementia, fell at a group home and is taken to the emergency department. Review of x-rays reveal a displaced right femoral neck fracture. The orthopedist documents the options he discussed with her son, which included non-operative management, closed reduction, open reduction, and internal fixation and hemiarthroplasty. The son wishes to proceed with the hemiarthroplasty, so the patient will be admitted and the surgery scheduled as soon as possible. Should a consult be billed?

Coding Advice: Not if the patient is a Medicare beneficiary, say our experts. Their rationale is that no one but an orthopedist can fix a displaced femoral head fracture. Therefore, the intent in calling the orthopedist was to transfer carenot to request an opinion or evaluation. (The fact that the orthopedist discussed options with the patients son does not influence the coding as far as Medicare is concerned.)

Because the initial encounter took place in the ED, it would not be billed as subsequent hospital care. Instead, use an admission code (99221-99223) appended with a modifier -57 (decision for surgery). This modifier allows the E/M service to be paid within the 48-hour global period. Otherwise, any E/M done the day before or the day after the procedure will be denied.

Case 2: A 91-year-old woman fell and injured her right hip and was taken to the ED. The consult note says, she was referred to our facility by.... The orthopedist reviews the x-ray, which shows a displaced intracapsular fracture of her right hip. He notes he will proceed with an Austin Moore prosthesis as soon as possible. Should a consult be billed?

Coding Advice: Not for a Medicare beneficiary. The rationale is the same as above. Plus, the words referred are a definite tip-off to transfer of care. Instead, bill a hospital admit code appended by modifier -57.

Case 3: A 73-year-old woman was admitted for evaluation of a left hip fracture. Review of x-rays shows an intertrochanteric-subtrochanteric fracture of left hip. Orthopedist schedules open reduction and internal fixation. Should a consult be billed?

Coding Advice: Not for a Medicare beneficiary. Again, if no one but an orthopedist can fix the problem, Medicare regards that as a transfer of care. Thus, the initial encounter should be coded as subsequent hospital care (99231-99233) appended by modifier -57 (decision for surgery).

Case 4: A 79-year-old woman, who fell after getting dizzy, was brought to the emergency department with a great deal of discomfort in her arm. She was later admitted. The x-rays reveal an impacted or undisplaced fracture of surgical neck of the humerus. The orthopedists notes say, We were asked to see her for evaluation of her shoulder. After examination, the orthopedist recommends the patient be treated with a sling for three weeks and then started on an exercise program, noting, This will not have an impact on other medical treatment she needs at this time. Should a consult be billed?

Coding Advice: This scenario is less cut and dried than the preceding ones because the intent of the requesting physician cannot be determined. But given the unclear nature of the pain, the statement recorded in the orthopedists notes, and his recommendation as to how the condition was to be handled by the primary physician, an inpatient consultation (99251-99255) should be appropriate, even for Medicare.

Case 5: An 88-year-old woman, who had her right hip internally fixed two years ago, was admitted to the hospital by her primary care physician because she was experiencing pain in her hip and leg, had a draining fistula in her groin, and anemia. The orthopedists consult report contains an extensive examination, x-rays, impression and discussion, which included the following statement: At this point, I think she should be treated very conservatively. Therapy would probably aggravate her condition. She is best treated with some medication and positioning. We will try to get her up in a chair and see if she tolerates that at all before she is discharged. Then, if there is no change, I think she could be discharged tomorrow morning. Should a consult be billed?

Coding Advice: Yes. A consultation would be the correct way to code for Medicare patients because the orthopedist rendered an opinion as to how the primary physician should treat the patient. The statement We will try to get her up in a chair.... does not disallow the consult. Neither does writing a prescription or other order. Both HCFA and CPT say the receiving physician (i.e., the doctor who receives the request for consultation from the physician who is making the request) can initiate diagnostic and therapeutic treatment. However, HCFAs interpretation implies that the requesting physiciannot the receiving onewould actually carry out the treatment recommended by the orthopedist.