Wiki Hospital Consultations

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lpalladino

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Huntington Station, NY
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If a resident is called in to consult an ER patient, and my provider is the on-call physician and we sign off on the residents note/recommendation but never actually saw the patient, are we as the on-call, non hospitalist, physician allowed to bill for the consult?
 
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Look at 99446-99451. There has to be a verbal and written report (just signing off on someone else's notes isn't a written report).

Consultant codes99446-99449 and 99451:
  • can be reported for new or established patients
  • can be reported for a new or exacerbated problem
  • are reported only by a consultant when requested by another physician/QHP
  • cannot be reported more than once per seven days for the same patient
  • are reported based on cumulative time spent, even if that time occurs on subsequent days
  • are not reported if a transfer of care or request for a face-to-face consult occurs as a result of the consultation within the next 14 days
  • are not reported if the patient was seen by the consultant within the past 14 days
  • require that the request and the reason for the request for the consult be documented in the record
  • require verbal consent for the interprofessional consultation from the patient/family documented in the patient’s medical record
 
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lpalladino said:
Just to be clear, then my MD cannot bill out a 99284 when the hospital resident/PA sees the patient. We have to have face-to-face contact in order for billing, or just a separate note?
Click to expand...

Resident and PA are two different situations. When you say resident, do you mean that this is a resident in a physician training program of which your provider is the teaching physician? If so, then no, the MD may not bill unless they document all of the following:
● That you performed the service or were physically present during the critical or key portions of the service furnished by the resident and
● Your participation in the management of the patient

Here are the CMS guidelines on residents and teaching physicians:
 
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We are just on call physicians, not hospitalists (we don't work for the hospital, just have privileges) so the residents work for the hospital as well as the PA's. Neither are under our TIN. We would be billing private practice TIN not hospital TIN
 
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OK, I think I understand, but the answer would still be no. With the exception of a 'shared visit' in which a physician and their own mid-level each perform a portion of an E/M service, in the hospital setting a physician may only bill for services that they personally perform - in a facility, 'incident to' billing is not allowed. And a physician cannot bill for the work of providers who are not their employees.
 
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Also be careful with your word "Consult". Physicians use this word all the time, but rarely does the situation and documentation actually fit the requirements for billing a consultation code. CMS audited "consultations" for three years and found out that 95% of them did not meet the requirements for a consultation which is why CMS and about half of all other payers don't pay for any type of consultation code any longer.
 
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