IP OP and consultation codes
Office visit
Office visit is divided into subcategory of new patient and established patient.
Consultation
To bill the consultation, 3R are required.
R: Request by the PCP, this is also recognized as referring physician
R: Rendering, Consulting physician render (provide) the service
R: Report back, consulting physician send report back to the PCP with thank you note.
If any R is missing, then consultation cannot be coded.
Medicare has stopped paying the consultation code from 2010. To solve this, physician would be billed with cross walked code.
Outpatient Consultation
Consultation can be billed only once. Subsequent visit with the consulting physician in outpatient is billed with office established patient codes (99212 to 99215. Outpatient consultation is coded with following codes:
Scenario
Example 1 (Non-Medicare): A cardiologist is requested by a primary care physician to provide their expert opinion on a patient’s heart condition. The cardiologist spends 45 minutes with the patient, discussing their condition and providing advice and reporting back to PCP with thank you note. In this case, the cardiologist would bill using the outpatient consultation code 99244 (Based on the time).
Example 2 (Medicare): A similar scenario as above, but the patient is a Medicare beneficiary. The cardiologist would bill using the appropriate E/M code instead of the consultation code and here it would be billed with 99204.
Inpatient - Hospital care codes
Hospital or observation care codes are divided based on the initial visit, subsequent visit, and discharge visit.
Date: December 31, 2023
Morning - Admission: Mr. Sharma, a 65-year-old male, is admitted to the hospital with severe chest pain. The attending physician, Dr. Patel, evaluates him and suspects a heart condition. Dr. Patel documents an admission note detailing Mr. Sharma’s symptoms, medical history, and initial treatment plan. This admission note is then billed.
Evening - Progress Note: Dr. Patel visits Mr. Sharma again in the evening to assess his condition. He notes that Mr. Sharma’s chest pain has lessened due to the medication. Dr. Patel documents a progress note outlining the patient’s response to treatment and any changes made to the treatment plan. However, only the admission note from the morning is billed for this day.
Date: January 2, 2024 - Discharge: on January 2, 2024, Dr. Patel sees Mr. Sharma in the morning and makes a progress note. However, this progress note is not billed separately. Later in the evening, when Dr. Patel discharges Mr. Sharma, a discharge note is prepared and billed. So, for this day, only the discharge visit is coded and billed. This is in line with the usual practice where only the most significant visit (in this case, the discharge) is billed on any given day.
AI Modifier:
AI modifier is appended to H&P note done for admission purpose when the payor is Medicare.
The AI modifier is used to identify the principal physician of record during an inpatient admission. This modifier should only be used by the admitting or attending physician overseeing the patient’s care during a hospital or nursing facility admission.
This modifier can be appended with 99221 to 99223, 99304 to 99306, and critical care code when critical care was warranted at the time of admission.
June 1st:
Dr. A performs the admission which is an H&P note. This is billed with codes 99221 to 99223 with an AI modifier for Medicare.
Dr. B performs a consultation which includes all 3R (request, render, and report back). As Medicare does not accept the consultation, it is cross walked to codes 99221 to 99223.
June 2nd:
Dr. A performs a progress note, which is billed with codes 99231 to 99233.
Dr. B performs another consultation. However, as per the guidelines, a consultation can be billed only once per specialty per stay. Hence, it is billed with codes 99231 to 99233.
June 3rd and June 4th:
On both these days, Dr. A performs a progress note, which is billed with codes 99231 to 99233.
June 5th:
Dr. A performs the discharge. If the discharge time is up to 30 minutes, it is billed with code 99238. If it’s more than 30 minutes, it is billed with code 99239.
