This article is part of a series on appropriate billing/coding of E/M (Evaluation and Management) services. It addresses follow-up hospital or nursing home inpatient consultations (CPT 99261-99263). The continuing goal of WPS is to assist providers in correct billing of E/M visits for reduction of payment errors.
Jurisdictional data analysis for E/M services 99261-99263 was obtained for dates of service 1/01/03 - 6/30/03 and paid dates 1/01/03 - 9/30/03. It indicated a frequency rate of greater than three services per patient for inpatient follow-up consultations for a large number of providers in comparison to other physicians in the jurisdiction. The data suggests that many providers may be billing these services incorrectly.
Current Procedural Terminology (CPT) defines a consultation as a "type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." The criteria include:
A request for consultation from an appropriate source documenting the need for the consultation. An appropriate source would include: physicians and certain non-physician practitioners, e.g. PA, CRNA, NP, CNS
For an inpatient consultation, the consultant's recommendation regarding the diagnosis, evaluation and/or treatment must be documented in the patient's shared chart.
Follow-up consultations are visits to complete the initial consultation. If the consultant initiates treatment at the initial consultation, then participates in the patient's care and management after the initial consultation, the codes for subsequent hospital care should be used (CPT 99231-99233).
An example of correct billing would be:
A hospitalized patient is being managed by a Family Practice physician, who requests a consultation from Internal Medicine. The Internist sees the patient in initial consultation and orders diagnostic testing needed to make a definitive diagnosis and subsequent treatment plan. An initial inpatient consultation is billed. The Internist sees the patient in follow up, to discuss the test results and consults with the requesting physician. Billing that visit as follow up consultation (99261-99263) is appropriate, as the Internist was not able to complete the consultation at the initial visit, due to needing the results of critical diagnostic tests. If on the second visit to complete a consultation, treatment is initiated and that portion of the patient's care is assumed, then a subsequent inpatient visit should be billed in lieu of a follow up consultation.
An example of incorrect billing:
A hospitalized patient is being managed by a Family Practice physician, who requests a consultation from an Endocrinologist regarding the patient's diabetes. The Endocrinologist sees the patient in initial consultation and initiates insulin therapy. An initial inpatient consultation is billed. The Endocrinologist continues to follow up with the patient, managing and/or addressing the diabetes treatment initiated at the first visit. It would be inappropriate to bill these visits as follow-up consultations (CPT 99261-99263). The follow-up visits should be billed using the appropriate subsequent hospital care code (CPT 99231-99233), as the Endocrinologist is managing part of the patient's care.
In both examples, the documentation criteria for the use of a consultation code must be met and be present in the patient's medical record. If more than 50% of the face-to-face encounter between the physician and the patient involves counseling/coordination of care, billing for the consultation may be based on time.
Sources of Information:
NCD National Coverage Decision, PHYS-006, Consultations
Information in this article is based on references as noted. In the event of any discrepancy with the information in this article, applicable National Coverage Decisions are the final determinants.
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