Wiki Consultation Codes

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slkeane18

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Our providers are beginning to use consultation codes (99241-99245) here in the office if there is a provider referring their patient to us. We are aware this patient can be new or established with our office and Medicare does not do this. However, we have two questions:

1. In the referral, does the SPECIFIC provider have to be the one who is being referred? Or can it just be the practice name? Example: Dr Christopher Roberts versus Center for Orthopaedics and Sports Medicine. Would Dr. Roberts be eligible to see this patient and bill for a consult code even if his name was not listed on the referral, but his practice was instead?

2. If the patient was seen by us for their right knee a year ago and the referral that we recently received is for a right knee consultation, would that be eligible for a consult code even if we have treated in the PAST?

Thank you!
 
The misunderstanding, overuse and abuse of consultation codes is why over 90% of carriers (not just Medicare) will no longer pay them. The physician meaning of consultation is very different than the coding requirements of a consultation. I suggest you read the requirements for consultation CPT codes. IF (and its a big if) the services meet all the requirements, AND the carrier recognizes them, 9924x is appropriate. Otherwise, you should be billing 99202-99215. Even in subspecialties, we rarely if ever use consultation codes any longer.
A forum search of "consultation" will provide you with plenty of references.
 
Agree as above. Also, rare for any payer to cover a consult code except maybe WC (still rare) or a random MCD plan. I would suggest you read the CPT guidelines for the definition of a consult code and what must be met.
What conference or peer were the providers "talking to" that they suddenly started coding these? Is it only one provider or all providers? Who made that decision? ;):LOL::ROFLMAO::geek: Sounds like Dr. Roberts is new to your practice and maybe came from another group, hospital, or new grad who may need your coding guidance. Side note - if you have a new provider to the practice they should be on 100% coding review for a period of time for just this reason. Also, be on the lookout for sudden coding changes when they return from conventions and conferences when they were, "talking with their friends/peers" from other states and practices.

Most internal coding systems have an edit set up for these CPTs for this specific reason. Even if a provider codes it, it should stop for coder review because it is most likely incorrectly coded.

Google or look up the "3 Rs" for consults.

In my work as an auditor, what I see is, even when/if a rare payer allows consults, they are rarely (to never) coded or documented correctly.
 
Brenda1973 said:
My question falls a little differently than the above discussion but wondering if you could help me please? If a medical office patient is referred to the ER and my provider does nothing under "risk of complication and/or morbidity " on the MDM table. Does that fall into 99212 "consult/referral without elaboration" or would it be under high risk 99215 " Decision or consideration for hospitalization or alternative levels of care." ? I have to educate providers on this and I am not sure of myself? Any advice?
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Hi, Brenda. I'd recommend posting you question as a new thread on the board. You are far more likely to get an answer than having your question buried in another thread. Regardless, I hope you get your answer soon 😊😊😊

Tracy
 
Brenda1973 said:
My question falls a little differently than the above discussion but wondering if you could help me please? If a medical office patient is referred to the ER and my provider does nothing under "risk of complication and/or morbidity " on the MDM table. Does that fall into 99212 "consult/referral without elaboration" or would it be under high risk 99215 " Decision or consideration for hospitalization or alternative levels of care." ? I have to educate providers on this and I am not sure of myself? Any advice?
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Is your provider the ED provider? I am not fully understanding the question. How do you mean they "did nothing?" We would need more specific info to help.
 
amyjph said:
Is your provider the ED provider? I am not fully understanding the question. How do you mean they "did nothing?" We would need more specific info to help.
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My providers are Telemedicine. They are not ED providers, they are all virtual care. Some visits are just not treatable via telemedicine such as an (object in ear, chest pain, severe allergic reaction, child with UTI symptoms, ect.) in those cases my providers (MD's and NP) will refer them to in person care such as (walk-in clinic or ER). In those cases when I say "nothing was done ", I mean medications where not discussed, no written referral, no plan, nothing other than a diagnosis and a statement of "this is not on the telemedicine platform, and you need to be seen in person." Where does this fall on the "risk of complications" table? or do I need to decide myself as far as chest pain is more of a risk than object in an ear? I'm reading all of the wording under 99212-99215 under "risk of complications" on the MDM cheat sheet or graph for EM levels 99212-99215 and it's just not black and white to me as which category this falls under. Some providers give this 99215 because they feel it's serious, other providers give it a 99212 because they are not treating the problem addressed, they are referring it to another provider (the walk-in clinic or ER). I hope this makes sense and you can advise me. Thank you!
 
If the E/M is based off MDM, and your provider can't treat the patient due to the circumstances, I don't see it as a billable visit. If they can't treat the patient, how can they get credit for MDM?
 
Brenda1973 said:
My providers are Telemedicine. They are not ED providers, they are all virtual care. Some visits are just not treatable via telemedicine such as an (object in ear, chest pain, severe allergic reaction, child with UTI symptoms, ect.) in those cases my providers (MD's and NP) will refer them to in person care such as (walk-in clinic or ER). In those cases when I say "nothing was done ", I mean medications where not discussed, no written referral, no plan, nothing other than a diagnosis and a statement of "this is not on the telemedicine platform, and you need to be seen in person." Where does this fall on the "risk of complications" table? or do I need to decide myself as far as chest pain is more of a risk than object in an ear? I'm reading all of the wording under 99212-99215 under "risk of complications" on the MDM cheat sheet or graph for EM levels 99212-99215 and it's just not black and white to me as which category this falls under. Some providers give this 99215 because they feel it's serious, other providers give it a 99212 because they are not treating the problem addressed, they are referring it to another provider (the walk-in clinic or ER). I hope this makes sense and you can advise me. Thank you!
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There is a wealth of information on telehealth out there. Just get it from a reputable source like CMS, AAFP, ACEP, etc. And, make sure it is info for Post-PHE.
I would argue that there may be MDM if they told them to go to the ED or they need to be seen in person, is that not medical decision making? The decision that this is not something that can be handled via audio/video?
It is a fine line and very iffy so you would need to take each encounter individually. However, if it took 2 minutes and the provider was like, nope go to ED now that may not be something that can be billed.

If this is family practice, you can read up on some scenarios here: https://www.aafp.org/family-physici...-telehealth-audio-virtual-digital-visits.html
AMA telehealth resources: https://www.ama-assn.org/practice-management/digital/ama-telehealth-policy-coding-payment
HHS: https://telehealth.hhs.gov/provider...ng-and-coding-medicare-fee-for-service-claims
CMS: https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf

The documentation and coding guidelines still apply. You would have to review the documentation for each individual visit to determine if it meets the requirements to be coded/billed or not. It depends on the nature of the visit and the documentation.

There are some other G codes (payer dependent) for things like quick check ins to determine if someone needs in person care, however they have specific requirements and uses. example: https://codingintel.com/virtual-communication-codes/
 
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