Wiki Inpatient Consult Coding

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I need some guidance or rather confirmation because I'm worried about my credentials and an audit.
Scenario 1: MFM Physician bills consults and only 99243's in the office 98% of the time regardless of documentation and the patient is followed through the end of their pregnancy and 99243 is always used on follow up visits as if it's still a consult.
Scenario 2: MFM Physician bills for Inpatient 99251-99254-POS 21/Follow up consults 99232-99233 POS-21 but they do not ever go to the bed side or on the floor to see them; they see them only in the office POS 11.
Scenario 3: Patient's are brought from the hospital to the office to have their ultrasounds 76819/76817/76911 or 76816 with POS 11 but charge IP consult codes POS 21 with the scan(s). They do this because they insist our equipment is better and that they have talked to "their colleagues" and this is the way it's done.
My position on Scenario 1 is if we get a referral for the office consult and the patient is scheduled out till they deliver due to the high risk pregnancy then the E/M established follow up codes should be used and not consult codes. It's not like we are confirming or reconfirming high risk issues. Is my thinking incorrect? Scenario 2: I don't think we should ever charge inpatient codes if we didn't go to the hospital to see the patient and provide a "consult." Really-do I need to retire my credentials or find a new job? Scenario 3: IDK Pls help!
 
For a consult inpatient, office, or outpatient you must have the 3 Rs
Request- there must be a request from another provider for your physician to see the patient for an issue that is unknown or treatment is unknown
Render- your provider must see the patient face-2-face and exam and the render a decision regarding the unknown issue back to the requesting provider
Report - the rendering provider must send a formal written report back to the requesting provider and both must have copies in the patient chart.
Scenario 1- you could argue that the first encounter is a consult but it will largely depend on the documentation. However the follow up visits are just follow up and in the office setting will be billed as est patient encounters. In the inpatient they will be subsequent inpatient. Or do you mean the patient is brought to the office while still an inpatient.
Scenario2- at no time can you bill a visit level without seeing the patient face to face.
Scenario 3- you will use POS 21 if the patient is a registered inpatient status, even though the service is rendered in your office but you must use the appropriate ultrasound code. At no time is it allowable to substitute codes, especially procedure codes for visit level.
I don't think you need to throw in the towel or throw out the baby or whatever, however you do need to correct this billing.
 
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Debra
The patients are always inpatient status, most are hospital bed bound from 24w to term. They are brought to the office and charged scans in ofc as POS 11 and consults as in patient POS 21- separately billed. I have tried to educate but the comments are that it is correct because the colleagues do it that way, insurance companies are paying them and if it were wrong then the insurance companies haven't ask for money back. I explained to her that ..yet..they haven't asked yet! She said to show where it's wrong..I showed the CPT codes verbiage and guidelines..3r's..etc...It's not getting through. How do you get through to Providers who don't value expertise over misguidance and don't want to sacrifice revenue by doing it right; instead looking for other ways to increase productivity and marketing to fill the schedules with patients instead of placing a practice at risk.
 
First you need to look up the POS guidelines.. These while not new are recent within the last few years. This states that the POS must be the place where the patient is registered not necessarily where the service take place. They even give as an example a patient brought to the provider office for tests or other services while still an inpatient, the POS for these services must be inpatient, 21 for acute inpatient or which ever fits the patient inpatient status. You cannot code a visit level and the ultrasound when the purpose of the encounter is rescheduled for the ultrasound. And you cannot bill a consult for the same patient for every encounter. Payers pay claims based on electronic edits which are not perfect and do not catch every issue. My hey work off of logic for the most part. If the claim is a logical claim for medical necessity then it is usually passed thru.
It may be the dx code they use, especially if they change the code for each encounter.
I am at a loss as to how you will handle this with the attitudes you are up against. However it is your responsibility to submit a claim that the documentation will support. If you are uncomfortable changing the codes to what is correct, then you may have no choice but to look for employment elsewhere.
You could always contact the payers and request an audit for these claims.. Risky but it could work.
I personally would change the change the codes and face the consequences.
 
Debra-you are awesome! Thanks for your candid response. I have been in the arena for so long and took this position thinking I could make a difference and thought that I could educate, but my expertise is not trusted and make me second-guess myself and my skills are sacrificing. I should have looked at the POS guidelines first but I just knew it wasn't right. I really appreciate the guidance.
 
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