Wiki Emergency Dept Consultations

[BarkerP]

I have a provider that is wanting to stay away from ER Consult codes 9928X because of reimbursement purposes as they have lower RVUs. For context purposes, I work for specialty providers who regularly get called to the ER for consults. I have found some articles recommending the use of Outpatient Consultation codes (99241-99245) as a replacement for higher RVUs. Has anyone else had experience using these codes instead of ER codes?

On a second note, he is considering using 9920X-9921X also as an alternative to ER consult codes. I do not feel these are appropriate at all as they do not contain any consult component in their description.

 

[CodingKing]

You cannot pick and choose based off the RVU. If ER physician calls in the physician to consult the ER codes need to be used.

For example from CMS on page 5 states:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm6740.pdf

If the ED physician requests that another physician evaluate a given patient,the other physician should bill an emergency department visit code. If thepatient is admitted to the hospital by the second physician performing theevaluation, he or she should bill an initial hospital care code and not anemergency department visit code.

Now If it was outside the ER, CMS (and many commercial payers that follow CMS) do not accept consultation code range thus office/other outpatient E&M code would be used in that case. It is also addressed in the link above.

 

[thomas7331]

CPT instructions do state that the consultation codes 99241-99245 may be used for consultations services in the ER, so that would be correct for payers that still accept those codes. For Medicare, which does not accept consultation codes, guidelines state that you are required to use 99281-99285, as the post above indicates. Those are really the only two options, unless your payer has a policy that allows for something else.

 

[BarkerP]

CPT instructions do state that the consultation codes 99241-99245 may be used for consultations services in the ER, so that would be correct for payers that still accept those codes. For Medicare, which does not accept consultation codes, guidelines state that you are required to use 99281-99285, as the post above indicates. Those are really the only two options, unless your payer has a policy that allows for something else.

Thank you Thomas for the feedback. I needed to clarify that the two different code sets were an option; albeit, depending on each specific insurance. From my experience, if a provider has an option between two code sets, they are going to use the one with the highest value.