What are some reasons to consult a hospitalist? Hospitalist comanagement is a growth field for our specialty, especially with the demise of consult codes. Before Medicare got rid of consult codes we had to document the three Rs to not be accused of fraud
** Requesting physician must be documented.
** Rendering an opinion to a question being asked.
** Response must be documented, usually in the form of written communication back to the physician.
Requesting a consult should be about asking for an opinion to a question. The thing that always got me was the "medical management" consult. Medical management is not a request for an opinion. It is a transfer of service. Medicare considered consult billing for a medical management to be fraud. But there was always a gray line to follow. Was that medical management consult for a home diabetic with a blood sugar of 129 considered an opinion on the patient's uncontrolled diabetes? Was the request to handle the post operative spine patient's blood pressure of 136/79 considered a consult for opinion on uncontrolled hypertension?
** Requesting physician must be documented.
** Rendering an opinion to a question being asked.
** Response must be documented, usually in the form of written communication back to the physician.
Requesting a consult should be about asking for an opinion to a question. The thing that always got me was the "medical management" consult. Medical management is not a request for an opinion. It is a transfer of service. Medicare considered consult billing for a medical management to be fraud. But there was always a gray line to follow. Was that medical management consult for a home diabetic with a blood sugar of 129 considered an opinion on the patient's uncontrolled diabetes? Was the request to handle the post operative spine patient's blood pressure of 136/79 considered a consult for opinion on uncontrolled hypertension?
What many doctors want is simply not to deal with the medical issues at hand. They want a transfer of care. Surgeons get paid a global fee for patient care. In clinical reality, that global fee doesn't cover the patient, it covers the surgery. While a rare surgeon likes to do it all, most prefer not to deal with anything outside the surgical needs. They have neither the time, energy, experience nor desire to manage medical issues that arise.
One thing I will not allow is to be treated by other physicians as their house officer. When I am asked to provide a history and physical, I inform the requesting party that a history and physical is not a billable CPT® code. I am more than happy to provide my pre operative opinion on the need for further evaluation from an internal medicine stand point, if that is the question being asked. All surgeons are capable of performing a history and physical. Producing an H&P is basic third year medical school skill.
As a hospitalist, I am not the house officer or the physician assistant or nurse practitioner for other surgeons and medical physicians who don't want to handle the annoying little details of being a doctor. If they want someone else to make their lives easier, they should hire an NP or PA to be that person. As a hospitalist, it's an uphill battle because we are seen as the doctor of convenience. If we as hospitalists allow ourselves to become convenience doctors, we will not survive the daily grind. One of my daily missions is to establish the ground rules.
As a hospitalist, I am not the house officer or the physician assistant or nurse practitioner for other surgeons and medical physicians who don't want to handle the annoying little details of being a doctor. If they want someone else to make their lives easier, they should hire an NP or PA to be that person. As a hospitalist, it's an uphill battle because we are seen as the doctor of convenience. If we as hospitalists allow ourselves to become convenience doctors, we will not survive the daily grind. One of my daily missions is to establish the ground rules.
With that said, hospitalist co-management is a growth field for our specialty. Defining management requires diligence to prevent the denigration into house officer status. As a hospitalist, when I am asked to see a patient in consultation for medical management, I no longer have to worry about whether I'm committing fraud by rendering an opinion to a question. Medicare never considered medical management to be a consult and in doing so created criminals out of physicians just doing the right thing. I make a determination as to whether there are any medical management issues that need addressed and whether my daily services are necessary. If there are not, I sign off the case and expect the admitting physician to handle the day to day questions that may arise during their rounds.
As of January 1st, 2010 the consult codes have been replaced by the admission history and physical codes 99221-99223. But that's not how I manage them. Rarely do I need to do a complete history and physical exam for diabetes or hypertension consults. I used to rely heavily on the inpatient level three consult 99253 for doctors asking me to render my opinion on their patient with a blood pressure of 121/83.
But a funny thing about Medicare. Their rules are highly arbitrary. Why a level three consult and not a level four or level five consult? Because the level three consult used to be the dividing line between a lot of work and a little work. In order to submit a bill for a level four or level five inpatient consult, according to the Evaluation and Management rules, I would have to perform a full review of systems and a full history and physical examination and I'd have to dictate the note as my response to the requesting physician. That is something I find preposterous. There is simply no reason to perform a complete history and physical nor a complete review of systems in a patient without a decompensating chronic illness. I relied heavily on the level three consult 99253, which in my state paid about $115.
While the consult codes are still available for nonMedicare payers, I have pretty much stopped using them. What am I using instead? The 99253 consult code has the exact same requirements for E/M rules as does the lowest level hospital admission code 99221.
- A level 1 hospital admission code 99221 = a level 3 consult 99253 for E/M rules
- A level 2 hospital admission code 99222 = a level 4 consult 99254 for E/M rules
- A level 3 hospital admission code 99223 = a level 5 consult 99255 for E/M rules
I had been heavily relying on my level three consult codes because that is the cut off between a lot of work and a little work. There is no reason to perform a complete H&P for medical management consult requests. As you can see a level three consult is the equivalent of the lowest level hospital initial hospital admission code 99221. So how much does Medicare pay for each of these codes? Here is an explanation of RVUs and how Medicare determines their final payment schedule. As you can see, it varies by geographic location.
In my state Medicare used to pay approximately $115 for a level three consult (99253). They currently pay about $93 for a level one initial visit admission code (99221). You can see there is about a 25% reduction in payment for the admission vs consult fee. I've discovered, however, that the high level hospital follow up code 99233 is more indicative of the medical decision making component of E/M. By the time I've reviewed the pre op EKG and and CXR, talked with the nurse, figured out the starting dose of coumadin, and reviewed the status of multiple chronic medical conditions, I've met the requirements of a high level 99233 hospital follow up visit. In fact, for most of these surgical patients, a preoperative history and physical has been performed within the previous week or two by their primary care physician.
I no longer dictate low level new patient encounters. I jump right to the undictated high level hospital follow up visit 99233 (if they qualify), which actually pays about $5 more for half the effort of a low level admit or mid level consult. This comes in especially handy when I receive a post operative surgical request for hospitalist to see prn. Yes folks, that actually happens. You can find a bunch of my medical billing and coding lectures to help you navigate hospitalist CPT® coding.
