Orthopedic Coding Alert

Contrary to what many coders believe, more than one physician can bill consultation codes for the same patient on the same day, even if the physicians all work for the same practice.

The key to reimbursement is ensuring that each physician manages a separate aspect of the patient's care and submits different specialized diagnoses on their consultation claims. By now, most orthopedic coders are familiar with the three R's of consultations: The consult codes (99241-99263) can only be billed if another physician requests the orthopedist's opinion, the orthopedist performs a formal review (exam) of the patient, and the orthopedic practice sends a report back to the requesting physician. Although the three-R's rule is easy to remember and usually simple to apply, it doesn't answer every orthopedic consultation question. Same-Practice Consults Are OK Jeanne Smith, reimbursement specialist/auditor at Madrona Medical Group, a 45-physician multispecialty group in Bellingham, Wash., says many coders mistakenly believe that several physicians from the same practice can't bill consultation codes for the same patient on the same day. "Concurrent care is an area that frequently gets confusing, and coding correctly for the consultations means speedier reimbursement," Smith says. "It also means avoiding the paperwork and frustration that is created by denied or bundling claims."

Section 15506C of the Medicare Carriers Manual (MCM) states, "Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met."

Smith offers an example: "Say we had a gentleman in the hospital with a total hip replacement (V43.64) who also has COPD [chronic obstructive pulmonary disease, 496] and develops atrial fibrillation (427.31). The orthopedic surgeon requests that one of our pulmonologists consult and manage the patient's COPD and requests a consult from one of our cardiologists for the atrial fibrillation."

Both the pulmonologist and the cardiologist should submit their consultation claims using the diagnosis codes most pertinent to their care, Smith says. Because the consultations took place in the hospital, the pulmonologist would submit his or her claim using 99251-99255 with 496 as the ICD-9 code, while the cardiologist would file his or her claim using 99251-99255 with the diagnosis code 427.31. NPPs Can Request Consults Many orthopedic practices hesitate to bill consultation codes when a nonphysician practitioner (such as a nurse practitioner or physician assistant) requests the orthopedist's opinion. Some practices even balk at billing the consultation codes when a podiatrist or chiropractor logs the request. But all of these medical professionals are qualified to request and perform consultations. According to Section 15506 of the MCM, "Non-physician practitioners, e.g., nurse practitioners, certified nurse-midwives or physician assistants, may [...]