Medical Consult - Dead or Alive?

December 10, 2010
Bill Dacey

Can you still use the consult code for Medicare and private payers?

Question: My providers seem really confused about using consult codes for Medicare patients in the hospital. Is the use of admission codes confined to the day the patient is admitted? Also, we have heard that private payers aren't paying for any consults at all. What can you tell me?

Answer: You have two pretty distinct issues here - and it is important to get them right from both a fiscal and compliance perspective.

The change to Medicare inpatient consults is pretty clear. The relevant language from Transmittal 1875 is as follows:

"In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221-99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy."

I have heard of practices that change inpatient consult codes to follow-up visit codes (99231-99232) when the consult is reported on a day other than the day of admission. The transmittal doesn't say this. It says when you perform "an initial evaluation and management," use the admission codes. So do what it says. Your provider's initial evaluation (consult) may well be on the second or third day. Medicare Administrative Carriers and other carriers should have no problem with this.

The second question is even more dangerous. The managed care and commercial payer universe of payers does not often move as one. It is totally incorrect to assume that "they" have stopped paying for consults - inpatient or outpatient.

It is true that some private payers, and some plans within payers, have stopped reimbursing these codes - but in my experience to date they are in the minority. What you are more than likely hearing, as unpleasant as this may be to say, is a biller or coder that finds it easier to try and operate by one set of rules than to do the work to find out what the different rules are. Behavior like this will cost you a lot of money. The problem here is more likely your own staff than the private payers - at least for now.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This question originally appeared in the January 2011 issue of Physicians Practice.