Inpatient Consultation:
An inpatient consultation service provided to a. hospital inpatient 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. If there is a known transfer of care of a specified problem from the referring provider to the specialist, a consultation code is not supported.
Consultations in all settings are a source of frustration and confusion for many medical professionals. With inpatient consultation visits, the most important thing for you to remember as a medical biller or coder is to verify how the physician ended up seeing the patient.
When to Bill for a Inpatient Consultation?
- Consultations can only be billed out when requested by another physician or appropriate source.
- A consultation requested by a patient is not reported by using consultation codes;rather, it is reported by using the appropriate E/M code.
- When a patient requesting for a second opinion or a consultation does not meet the CPT definition of a consultation code.
When a physician performs a consultation for an inpatient, the request and reason for the consultation, as well as the consulting physician’s findings, must all be included in the patient record. When all this information is included in the patient’s record, a medical biller can then code these visits as consultations.
Requirements on Documentation:
- The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and must be communicated by written report to the requesting physician or other appropriate source and recorded in the chart note.
- Documentation of the written or verbal request for the consult from the requesting physician must be in the patient’s medical record and provided on the encounter form. The requesting physician’s name must be referenced on the CMS 1500 claim form.
Inpatient Consultations for Established Patients:
A consultation code may be billed out for an established patient as long as the criteria for a consultation code are met. There must be a notation in the patient’s medical record that a inpatient consultation was requested and a notation in the patient’s medical record that a written report was sent to the requesting physician.
Don’t use Inpatient Consultation Codes for Medicare Patients:
Note that there are specific coding requirements for patients who have Medicare as secondary insurance coverage, which we will handle accordingly. As Medicare no longer accepts consultation codes (effective January 1, 2010), the appropriate E/M code should be used for patients who have Medicare as their primary insurance. If the criteria for a consultation code is not met, do not bill a consultation code. Instead, select the appropriate E/M.