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Pulmonary & Critical Care Medicine
In an effort to support clinical income, the Revenue Cycle Management Committee has developed a new reference tool with answers to common coding and/or billing questions.
Updates will be distributed routinely by email with Billing/Coding questions and answers. Our goal is to provide clear and practical solutions to frequently asked questions. These emails will provide links to these pages where the same questions and answers will be readily available as an archive. If you have questions about the content of these updates, please feel free to contact either Margaret Henry or Kempa Carriere-Arnold.
QUESTION 1: When is it appropriate to bill for a follow-up consult? ANSWER
QUESTION 2: Is there a rule that only two follow-up consults may be billed per patient per admission? ANSWER
QUESTION 1: If a patient was discharged from the hospital and was readmitted to the same hospital on the next day, could I bill for the second admission service? ANSWER
QUESTION 2: How do I bill for a patient who leaves the hospital AMA (against medical advice)? ANSWER
QUESTION 1: When a patient notifies a specialist that his/her primary care physician is requesting that the specialist evaluate the patient, can this be considered a consult? ANSWER
QUESTION 2: If a patient is initially referred to a physician for a procedure and is subsequently seen for a problem which is made manifest by the procedure, is it appropriate to bill this visit as a consult? ANSWER
Per AMA 2004 CPT-4, follow up consults are visits a) to complete the initial consultation (i.e., the physician is not able to respond with the opinion or advice sought until more information is obtained), OR b) when subsequent consultative visits are requested by the attending physician.
The Office of Billing QA Documentation Guidelines state, "Follow up Inpatient Consultations, 99261-99263, these services are provided in the inpatient setting to complete the initial consult (e.g. test results are required prior to the completed of consult) or when re-requested to see the patient during the same admission."
If the consulting physician continues to participate thereafter in the patient's management, the codes for subsequent hospital care should be used.
References: 2004 CPT-4 AMA Manual, CPT Assistant Volume 11, Issue 11 November 2001, OBQA Documentation Guidelines 2003. (2.17.04)
We are not aware of a written rule that only 2 follow up consults may be billed per patient per admission. However, generally under normal circumstances it typically takes no more than 2 visits to complete the initial inpatient consultation OR re-request The OBQA (Office of Billing Quality Assurance) has not found references or written guidelines limiting follow up consults to a specific number, however prior advice has suggested that if more than 2 follow up consults are done, it may be more appropriate to bill subsequent hospital care services. (2.17.04)
It is appropriate to bill an initial hospital care day (99221-99223) for a patient who is discharged and readmitted on the next day when a complete history and physical are performed. The appropriate level of documentation should include the key components of a history, exam and medical decision making. (1.6.04)
Yes, this service could be considered a consult, if it can be accurately stated in the documentation for the visit that “The patient is seen in consultation for ____ at the request of Dr. Y.”
Please note that best practice is that the request comes directly from the referring physician (written or verbally). In all instances where a consult is billed, the written report must be sent back to the requesting physician. This level of documentation satisfies the CMS guidelines for consultations. (11.18.03)
In this situation, the appropriate way to bill for this service is as an established patient office visit or as a subsequent hospital care, depending on the setting. This is a subsequent visit to manage the patient’s condition and is therefore not considered a consultation.
Q. What if the subsequent visit is requested by a referring physician?
In this situation, the appropriate way to bill for this service is as an established patient office visit or as a subsequent hospital care, depending on the setting. If the patient is seen subsequent to a procedure at the request of a referring physician, the visit may be billed as a consult. This request should be documented in the patient medical record. (11.18.03)
These responses represent the Revenue Cycle Committee’s best advice to clinical faculty and providers upon the questions posed. It includes input from the Office of Billing Quality Assurance. If you believe you have extenuating circumstances or that a more in-depth discussion with your division is indicated, please notify Margaret Henry (firstname.lastname@example.org, 5-1629) or Kempa Carriere-Arnold (email@example.com, 0-8398).