Wiki ER Consult - which code?

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jdibble

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Our hospitalist was called to the ER to consult on a pediatric patient with a sore throat. The hospitalist did the consult and recommended that the patient be given antibiotics and be sent home. The hospitalist billed 99242. Now BCBS is denying claim stating that the procedure is inconsistent with the place of service and suggested billing the correct POS. They are denying this saying the 99242 is not payable in the ER.

Can someone offer what code we should be billing with? According to CPT this is the correct code for a consult in the ER, so I am not sure what they want. The ER doc billed the codes for the ER and since this is not a medicare patient, I know we can't bill that code too!

If anyone has any ideas of what code we should be billing - or if we coded this right, I would appreciate your response!

Thanks,
__________________
 
The problem is that you are using a "deleted" consultation E&M code! The E&M rules for consults have changed, now instead of using 9924x it becomes either a est pt., seen in your clinic within the last 36 months (99212-99215) or it is coded as a new pt (99201-99205).

Hope this helps :)
 
Consult codes have not been deleted

Check the '11 version - they are still valid codes - just some payers starting with CMS, do not reimburse for them.

To the original question - was the patient admitted from the ER? If so, they may be looking for the inpatient consultations - 9925x. Or, of course, the carrier may be one that followed CMS's lead and do not reimburse for consultations, as others have noted here.
 
"Consult" codes are gone in WA

Since you stated that the hospitalist recommended the pt to be send home, it's save to assume that at the time of the "consult" he was a outpt, so even if he was a ER admit, the "consult" would still be a outpt one, unless the hospitalist is the admitting physician (not according to your post).
Either way, whatever inpt/outpt consult, here in WA the "Consultation" codes are gone, not to be used, period!


Hope this helps, good luck! :)
 
Last edited:
jdibble said:
Our hospitalist was called to the ER to consult on a pediatric patient with a sore throat. The hospitalist did the consult and recommended that the patient be given antibiotics and be sent home. The hospitalist billed 99242. Now BCBS is denying claim stating that the procedure is inconsistent with the place of service and suggested billing the correct POS. They are denying this saying the 99242 is not payable in the ER.

Can someone offer what code we should be billing with? According to CPT this is the correct code for a consult in the ER, so I am not sure what they want. The ER doc billed the codes for the ER and since this is not a medicare patient, I know we can't bill that code too!

If anyone has any ideas of what code we should be billing - or if we coded this right, I would appreciate your response!

Thanks,
__________________
Click to expand...

When you are called to ER to see a patient at the request of the ER physician, then you bill an ER level with POS 23 just as the ER physician will do. Just because they are not a Medicare patient does not change this. It does not sound like a consult from what you have described. Also even though the codes are still valid many payers have adopted the CMS policy on consults, meaning they do not exist.
 
mitchellde said:
When you are called to ER to see a patient at the request of the ER physician, then you bill an ER level with POS 23 just as the ER physician will do. Just because they are not a Medicare patient does not change this. It does not sound like a consult from what you have described. Also even though the codes are still valid many payers have adopted the CMS policy on consults, meaning they do not exist.
Click to expand...

Thanks Debra and all for you help!

Debra,

So far our BCBS is still paying for Consults - we have not been notified of any changes. The Hospitalist was called to the ED to render their opinion on whether the pediatric patient should be admitted or sent home, so that is why they used the consult code. POS was billed as 23. The patient was sent home - they were not admitted to the hospital. You say this does not sound like a consult, then what would it be considered? If I submit with the ED codes for this physician, won't they deny as duplicates since the ER doc billed with these codes?

Thanks for your continued assitance!
 
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