Billing a Hospital Follow-Up Code Instead of a Consult Code

Hospitalists usually get all those consults for uncontrolled diabetes or hypertension for patients admitted by doctors for something completely unrelated to the consult request.  Often times these are very straight forward consults with minimal effort required.  How do you bill the simple straight forward consults?  As you know, Medicare got rid of consult codes on January 1st, 2010.   I still bill the consult codes because I never know what insurance the patient has.  I have provided an exhaustive review of this exact situation and others on my lecture describing how to pick the correct H&P code.

If I bill a consult on a Medicare patient, my billing company will convert it to the appropriate initial hospital visit code (99221-99223) that physicians have been directed to use in place of the consultation codes in the hospital setting. Some non-Medicare insurance companies will still recognize the consults codes (99251-99255) so I still submit them.  You can read all about these codes in the AMA's CPT 2018 Standard Edition, the definitive authority on CPT coding.  This resource is available below and to the right from the link to Amazon.

Rarely does an "elevated blood pressure" or "elevated blood sugar" consult rise to the level of a 99255 .  I am a big user of the level three consult.  What are the requirements for a level three inpatient (99253) hospital consult?  They are the same as a low level admit 99221, which are the same as a low level observation admission 99218 which are the same as the same day hospital admission and discharge 99234.

As you can see, you only need four HPI, a two point review of systems not twelve point review of systems, one area from past medical family and social history, six organ areas with two bullets each, and a low level medical decision making criteria.  How many relative value units (RVUs) does a level three consult pay?  According to the Medicare National Bank, a level three 99253 inpatient consult pays 3.18 relative value units (2.27 work RVUs, 0.8 practice expense RVUs and 0.11 malpractice RVUs)

While physicians have been instructed to bill the initial inpatient hospital codes for their initial consultation, providing the documentation for a hospital follow up visit may be more economically beneficial, if your documentation supports a high level hospital follow up code but does not have enough documentation to support an initial inpatient hospital code.

Here are the details.  A high level hospital follow up code (CPT® E&M 99233) is actually worth more in RVUs (2.0 work RVUs, 0.59 practice expense RVUs, 0.06 malpractice RVUs, 2.65 total RVUs)  than the lowest level admission code (CPT® E&M 99221) (1.88 work RVUs, 0.54 practice expense RVUs, 0.07 malpractice expense RVUs, 2.49 total RVUs).

In other words, if you normally bill a level three inpatient consult 99253,  the equivalent admission code is a 99221.  However, the high level hospital follow up code is actually worth 0.16 RVUs more than a low level admission code.  If you provide complete and thorough documentation of your evaluation, the high level follow up code can be justified based on the current E/M rules.

For the last seven years of hospitalist work,  I have frequently written just a hospital follow up code (usually a CPT® E&M 99232 or 99233)  when I have been asked to consult on a patient.  There is no dictation requirement in my hospital bylaws.   There is no complete history and physical exam.  I  don't need to meet ALL criteria of E/M coding,  just two out of three.  The documentation necessary to meet a hospital follow up code is less than an admission or consultation code.    Most of the time, a hospitalist can meet the requirements of a level three consult with a level three 99233 hospital follow up visit on their initial visit with correct and thorough documentation.

EM Pocket Reference Cards Using Marshfield Clinic Point Audit
Click image for high definition view

Print Friendly and PDF