Orthopedic Coding Alert

CPT will revamp consult coding next year

You can forget the rules you learned about distinguishing follow-up consultations from initial consults--CPT 2006 will most likely eliminate this distinction.

The AMA released the tentative agenda for its CPT 2006 Coding Symposium, to be held Nov. 17 and 18 in Chicago. The agenda gives the first official clues as to which areas next year's coding changes will address.

When the 2006 CPT updates take effect Jan. 1, 2006, orthopedic surgeons will face two major E/M changes. CPT 2006 will:

- delete follow-up inpatient consultations (99261-99263, Follow-up inpatient consultation for an established patient -) and confirmatory consultation codes 99271-99275 (Confirmatory consultation for a new or established patient -)

- clarify modifier 25's explanatory text to specify that  documentation must support the significant and separate E/M claim.

Here's what the changes mean to you.

Bill All Inpatient Consults as 99251-99255

This winter, you won't have to question whether an inpatient consultation is an initial or follow-up consult--a distinction that orthopedic surgery coders have long struggled to comprehend.
 
-Physicians never used the follow-up consultation codes correctly,- says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

New method: You-ll bill all inpatient consults as 99251-99255 (Initial inpatient consultation for a new or established patient -). Report follow-up inpatient care with subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient -).

How it works: When an orthopedic surgeon receives a proper request for a consult in the inpatient setting, you may claim one initial inpatient consult (99251-99255) per visit. These codes won't change for 2006. However, if the surgeon sees the same patient during the same inpatient stay, you should report subsequent hospital care codes, not follow-up inpatient consult codes (99261-99263, which CPT 2006 will eliminate).

Example: After an orthopedic surgeon renders his opinion on a heart-attack patient's hip tendinitis, the physician continues to check on the patient during his hospital stay. Because the orthopedic surgeon is managing the patient's subsequent tendinitis care, you should code the subsequent visits with 99231-99233.

Use Right Diagnoses to Capture Dual E/Ms

Pay attention to diagnostic coding to help you avoid denials for two same-day, E/M services that different specialists perform.

In the above subsequent care scenario involving the tendinitis/heart-attack patient, each specialist should report subsequent hospital care (99231-99233). Therefore, the insurer will receive two subsequent hospital care claims for the same patient on the same date of service.

Key: Each specialist must report the condition(s) he cares for to ensure multiple subsequent visits do not cause denials for concurrent care. -ICD-9 instructs the physician to list all of the diagnoses he or she addressed during that exam,- Callaway says.

For the tendinitis/heart-attack patient, the orthopedic surgeon should report an appropriate tendinitis diagnosis, and the cardiologist should code the myocardial infarction (MI).

Gain More Than $10 per Visit

Not only will CPT 2006 ease your inpatient coding, 99261-99263's deletion will benefit your bottom line.

Payment comparison: Codes 99231 and 99233 pay $11.75 more than 99261 and 99263, based on the 2005 National Physician Fee Schedule Relative Value File. Code 99232 reimburses $10.23 more than 99262.

Check Site, 3 R's for 99271-99275 Replacement

The new year will further whittle away your consultation code choices. CPT 2006 will also delete confirmatory consultation codes 99271-99275.

The replacement code for 99271-99275, however, isn't clear-cut. A confirmatory consultation could qualify as an office visit, an outpatient consultation or an inpatient consult, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.
 
To determine the appropriate code, look at the encounter's site of service and its consultation qualifications. If the visit meets a consultation's three requirements--request for opinion, rendering of services, and reporting back to the requester--you should report a consult code. But a confirmatory consult may not automatically be a consult.

Why: A confirmatory consult's source may not count as an appropriate source for an outpatient (99241-99245) or inpatient consultation (99251-99255). Although CPT permits a patient, a family member, an employer or an insurer to request a confirmatory consult, insurers may stipulate that a physician has to request a consult.

If the patient presents to you for a second opinion, generated by herself or her family, you-ll probably report a standard E/M code (99201-99215) in 2006.

Reserve Modifier 25 for Documented Cases

You probably know that you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to a visit only when the orthopedic surgeon's documentation supports a significant and separate service. CPT 2006, however, will reinforce this guideline.

The update will clarify modifier 25's explanatory text. The new explanation will state that a -significant, separately identifiable E/M service- should have documentation that meets the requirements for the E/M service being reported.

This solidifies most coding experts- recommendations that you should be able to lift the E/M documentation from your notes and it should stand as a completely separate service from what the surgeon performed during the procedure.