Orthopedic Coding Alert

Question: Our surgeon saw a non-Medicare patient in the office for a consultation, and then later the same day, the referring physician admitted the patient to the hospital and asked the surgeon to consult with the patient again. Should I should code an office consultation or an inpatient consultation or both?

Alabama Subscriber

Answer: You should report an inpatient consultation with a code from the range 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making) through 99255 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity …), depending on encounter specifics for both the office and hospital consultations.

According to CPT^® 2019, you should report inpatient consults when “an inpatient consultation is performed on a date that the patient is admitted to a hospital or nursing facility.” And, you should use the inpatient consult codes for “all evaluation and management services provided by the consultant related to the admission,” (emphasis added).

That means you should not report two separate consultations for the same date, but you should base the inpatient consultation code on the combined level of service from the two consultations.

If the surgeon had consulted with the patient only prior to hospital admission, you would report office consult services with codes from the range 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making …) through 99245 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity …), depending on encounter specifics.

That’s because CPT^® 2019 instructs you to use an office consult code when “a patient is admitted after an outpatient consultation (office, emergency department, etc.), and the patient is not seen on the unit on the date of admission.”