Consultations

I am beginning to bill for a dermatologist that performs inpatient consultations and nursing home consultations. I want to be sure I understand the guidelines especially since most of thes are Medicare. Inpatient consultations are limited to one per admission? Even if the diagnosis is different although it would still be derm?
Nursing home patients are often in the facility for years. Is the physician limited to one consultation per admit there also? Same questions, even if a year has passed and the diagnosis is a new one? Does the 3 year for a new patient change the status in any way?
At a recent conference I was told by a billing company the limit rule only applied to Family Practice and Internal Medicine not Specialists. That did not seem correct to me but I want to be sure.

Inpatient consults

CR4215 addresses the Centers for Medicare & Medicaid Services (CMS) consultation policy clarifications regarding the definition, documentation requirements, when and by whom a consultation may be performed/reported.
Medicare limits the inpatient consults to one/provider/episode of care.
Medicaid and commercial payers may be more restrictive (ex, 1 consult/6 months).
All criteria must be met and medical necessity documented.
In a Nursing home all consults must be medicall necessary. Consults are not New/established patient codes.

The inpatient consultation codes are used to report physician consultations provided to inpatients,residents of nursing facilities, or patients in a partialhospital setting. Only one consultation should be reported by a consultant per admission. Subsequentservices during the same admission should be reported using Subsequent Hospital Care Codes (99231-99233) orSubsequent Nursing Facility Care Codes (99307-99310),including services to complete the initial consultation,monitor progress, revise recommendations, or address a new problem. Specialty designation has no impact on the codes.

Nursing Home Consultation

If the patient has not been seen in 3 years by this dermatologist, but she has not be discharged from the nursing home, can the physician perform another consultation as a new patient?
I assume the commercial insurance's have their own guidelines, correct?

Consultations

Consults don't have new/established patient definitions, but are defined as outpatient or inpatient. You can bill a consult on a patient more than once (that is, on a patient for whom you have previously consulted) as long as the requirements of a consult are met, and it isn't follow up care. The three year rule is for new patients and doesn't come into play for consults.

For hospital inpatients, as you and Nancy have said, only one per inpatient.

Consults cannot be billed as shared or incident to.

And of course, if it's follow up care, bill the category of service that's relevant, subsequent nursing facility, etc.

New or established diagnosis doesn't matter, but if it is the same condition, you want to be certain that it isn't follow up to the initial consult, but is in fact, a request for advice/opinion/assessment about the treatment of the condition.

As I understood it...

you can have multiple consultations on the same patient if the problems are different and there is time between problems. So, a patient is admitted with abdominal pain and a rash. Derm is consulted for eval and recommends some cream and sees the patient once. Three weeks later the patient is post-op day 17, in the ICU, on a vent and develops a bed sore. Derm can be re-consulted to evaluate this new problem and can bill both as consultations.

Likewise a nursing home pt can have a rash one month and a new mole 2 months later=2 consults.

Am I wrong?

Consultations

The initial inpatient consultation may be reported only once per consultant per patient per facility admission.
Inpatient Follow-up to Initial Consultation: In the hospital setting, following the initial consultation service (99251-99255), the Subsequent Hospital Care codes (99231-99233) are reported for all additional follow-up visits.

One inpatient consultation per consultant per admission is allowed. Report subsequent hospital visit when:

Patient develops a new problem during the same admission
Consultant is asked to re-consult after signing off
Consultant follows up with new treatment options after testing and diagnostic intervention.

If the consultant performed an initial consultation prior to surgery, he cannot code another consultation in post-op period.

Then what's the point?

If you are limited to one consult per patient per admission, then why do the consult codes say "new or established"...why not just say one per admission? Let me ask about two scenarios...

1. I see an inpatient in consultation for cholecystitis, I recommend surgery and take the patient to the operating room for laparoscopic cholecystectomy. The patient stays in the hospital because of a pneumonia or UTI (or whatever reason). 4 weeks later (still inpatient) I'm asked to see the pt in consultation for sacral decubitus ulcer. One consult or two?

2. I see an inpatient in consultation for cholecystitis. I take the patient to OR for lap chole...pt discharged...One month later, the primary doctor asks me to see this patient in consultation in the office for an inguinal hernia. One consult or two?

And pandora's box opens...

I can't wait to hear the answers about those cases! It sounds like they are actually not consultations since you are assuming care for the problem (performing the surgery) and not just rendering an opinion.

pandora's box...

Here's the problem as I see it...As a surgeon, I'm not a technician. I don't just do procedures just because the primary thinks I should. Just today I was sent a patient for "gallstones" and I was asked to do a lap chole. As it turns out the patients main complaints were diarrhea and left lower quadrant pain...it had nothing to do with her gallstones...In other words, until I do the consult, I can't give an OPINION as to whether the patient needs surgery or not. And if I'm not mistaken, CMS says that as the consulting physician I can either order tests for workup or treat the patient. Keep in mind, that clinicians more often than not think of consults in this way. Last week an urgent care doc sent me a patient with an "inguinal hernia". In fact the patient had prostatitis. I rendered an opinion and called it a consult. I'd love to hear how the coding world sees this.

Consults

The "coding world" sees it as instructed by the AMA and CMS dictates. The Consultant does not determine the "intent" of the requesting physician, the attending makes the determination of consult or referral for management. The patient could be sent for management but upon evaluation the consultant decides surgery is not an option and sends the patient back to attending with his opinion and recommendations (a consult if all criteria met).
"Evaluate and treat" is not a consultation, it is management from get-go.

Criteria for a Consult:
The referring physician requests the consultant’s opinion or advice regarding evaluation and/or management of a specific medical problem. o The written or verbal request and need for the consultation are documented in the patient’s medical record. o After the consultation is provided, the consultant prepares a written report of his or her findings, which is provided to the referring physician (office), inpatient record serves this purpose of notification.
Specifically, per the Medicare Claims Processing Manual, Chapter 12, Section 30.6.10, a consultation service is distinguishedfrom other evaluation and management (E/M) visits because it is provided by aphysician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

consults

Well, here's where we run into the problem. I know it seems clear to the coders out there. But believe me, clinically the CMS definitions are frequently not black or white. For example, how the heck am I supposed to know if the requesting physician wrote the request in his/her chart. Are you kidding me? Secondly, any time I'm asked to see a patient I have to render an opinion....how does one differentiate an opinion from accepting care. I guarantee you that a physician didn't write that portion of the CMS requirements. The criteria you quoted from the CMS makes no sense. If I'm asked to see a patient with gallstones to evaluate, according to the criteria you've quoted...this could be a consult. There's nothing in that language that says it isn't. How exactly is the referring physician's request of opinion or advice known. Do you really think that in the real world requesting docs actually write I'm requesting an opinion for Dr. so and so for such and such a problem. It just doesn't happen. I send all my requesting docs a letter and a dictated copy of the consult note...so that meets criteria. The reason we have these discussions in the first place is because CMS is not very clear about much of its requirements...if it were, then we wouldn't need Codapedia. Thanks. I'd like to hear some lively debate on this.

consults

Well, I think Nancy's post and your post pretty much describe the consult problem, and the difficulty with transfer of care, and with intent. Transfer of care is very briefly described in the manual, and it is hard to know the intent of someone else, without specifically asking them.

Some groups require a fax or a copy of the requesting/referring physician's notes to help them decide on the requesting clinician's intent.

Transfer of care, per Medicare is described in this article:

http://www.codapedia.com/~article_47_.cfm

One other thing I'd check, is your ratio of consults to new patient visits. The CMS norm is 3.11 consults billed to every new patient visit. If your practice has no new patient visits ("All our patients are consults") then I would be concerned.

consuts

Thanks for the response. Does the 3.11 ratio apply to all fields. Do you know the ratio for general/colorectal surgery? I would assume (maybe incorrectly) that specialists would have a slightly higher ratio of consults to new patients...And also is that ratio for all E/M codes or just office consults (ie hospital consult/hospital admit vs. office consult/new office patient). I'm guessing my office ratio is roughly 5:1.

As I learn more about coding and billing I realize that most of the docs out there have no clue. I know docs who code only level 3 or 4 office consults no matter what. I've been told "cancers are 4s everything else is a level 3". Its a sad commentary on the system in general.

Thanks again for your comments.

Consults

Colorectal surgery:

2.15 consults to every new patient visit.
Office and outpatient consults to all E/M services: 19.29%
Initial inpatient consults to all E/M services 6.17%
All consults to all E/M 25.45%

Decisionhealth sells a book with this information: E/M Bell Curve Data Book, which I buy every year.

Finally one reason why is is beneficial to be an internist!

The only consult I bill is the pre-op eval and that is clearly allowed by CMS as long as I say "sent by" and "send copy of report to".

I am going to look for some orthopedists and see how they code- it can't get much more straightforward than a patient with a torn meniscus/fractured arm/hip fracture referred for care.