Wiki Established outpt in for inpt Consult

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amsmith

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I have a well established dialysis patient to my Nephrologist in the outpatient setting and there is an established treatment plan. The patient is admitted into the hospital and the admitting MD requests my Nephrologist or his immediate colleague to consult this patient for ESRD management.

I need the guideline that says that he cannot bill a consult on a patient that has an established treatment plan for that diagnosis. I have seen it a few times documented by the RPA and a few people on here, but I cannot find the guideline. I am confident that it will be cut and dry, but so far I cannot find the hardened evidence to support this statement. Please help!!
 
amsmith said:
I have a well established dialysis patient to my Nephrologist in the outpatient setting and there is an established treatment plan. The patient is admitted into the hospital and the admitting MD requests my Nephrologist or his immediate colleague to consult this patient for ESRD management.

I need the guideline that says that he cannot bill a consult on a patient that has an established treatment plan for that diagnosis. I have seen it a few times documented by the RPA and a few people on here, but I cannot find the guideline. I am confident that it will be cut and dry, but so far I cannot find the hardened evidence to support this statement. Please help!!
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If the admitting physician saw the patient and request the consult from the patients nephrologist then yes they would bill a consult or initial/subsequent visit dependent upon the documentation and dependent upon the insurance.

Maybe the RPA has a different set of guidelines? Curious to see other responses.
 
Seriously confused

I have asked the RPA for the guideline supporting their answer without a response. I sent a PM to the person in this forum who echoed the RPA again with no response to having a guideline. My original answer was the same as yours and I argued that for a long time now I am trying to prove myself wrong because I am meeting plenty of opposition due to the RPA asssuring my Nephrologists that they are correct. I cannot imagine the association printing this on their website and in a book for it to be wrong, but it happens. One other thing they said proved to be incorrect, so I simply do not know.

http://www.renalmd.org/Coding-and-Billing-FAQs/
Date Answered:10/06/2010
If a patient whose care is being followed by one of our nephrologist is admitted to the hospital by his/her PCP and the PCP calls our nephrologist in to see the patient, what would we bill the visit as (consult/initial, or subsequent)? The reason I am asking is because our nephrologists were told that if they already followed a patient for dialysis and were called in by the patient's PCP to do an inpatient consultation, they should not charge a consult they should charge a subsequent visit.
If the patient has Medicare as primary insurer, it is initial care (CPT codes 99221-99223); if it is commercial primary, they would bill subsequent.
 
Like any consult it would depend on the intent of the requesting physician. Does the PCP want your doctor's opinion on how to treat the ESRD, or are they requesting that your physician manage the ESRD while the patient is in the hospital? Based on your post it sounds like the PCP wants your docs to manage the ESRD which would not be a consult.
 
Intent is to hand over the kidney management.

The intent of the request is for the management of the kidney condition including the continued dialysis noting the treatment of the patient's kidneys will not be returned to the PCP for treatment. At this point, I am confident that it should be a subsequent for what is taking place, but my compliance department disagrees and feels it should be a consult and they have washed their hands of it requiring me to prove myself on my own. I know it has to do with the intent, but I have searched high and low and cannot find anything to prove to them that this is a subsequent and not a consult. It seems to me more like a transfer of care.
 
Since you're not having a problem with Medicare, I think your best bet is to search your other carriers for their specific guidelines and go from there.
 
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