- Request for consult. (A written order by the psychiatrist should be documented in the record and the consulting physician should document “Consult requested by Dr. Smith for evaluation of patient’s uncontrolled hypertension.”)
- Written report of his or her findings in the inpatient medical record. (The note may serve as a “report” and should clearly define the recommendations made by you, the consultant.)
Question # 2: Can the degree of complexity be considered higher than a typical patient with “uncontrolled hypertension” due to the difficulties in obtaining the information for this patient?
Answer: The complexity of data reviewed can have an impact on the level of service billed. The uncontrolled nature of the underlying problem, and the summarizing of the patient’s history from the record when the patient is unable to provide the information would be indicative of moderate complexity decision-making. Note that in situations where the level of service is much lower than the time spent with the patient due to extenuating circumstances such as these, it may be appropriate to consider “prolonged care” codes as long as the time thresholds are met and time is documented in the record.
Scenario # 2
A patient with stable hypertension and diabetes has been seen by one of the other members of your group and specialty for a preoperative consultation. The consultation was performed and the patient was deemed to be medically optimized. After the surgery, you are asked to co-manage the patient’s SAME medical conditions.
Question: Can I code an initial consult?
Answer: This is a situation where Medicare has a special rule for those physicians (same specialty and in the same group practice) who perform pre-operative consultations. A consult code (either initial or follow up) should not be used but rather a subsequent visit code should be used. An assumption is made that the physician who performed the preoperative consult will have developed a treatment plan for that problem and will have assumed responsibility for any postoperative care requested by the surgeon. HOWEVER, if a new problem has arisen and a consult is requested by the physician postoperatively, then an initial consult code may be used.
Postoperative Management of Medical Problems
According to Medicare’s carrier manual, “If a surgeon asks a physician to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking the physician’s opinion or advice for the surgeon’s use in treating the patient. The physician’s services would constitute concurrent care and should be billed using the appropriate level subsequent visit codes.” (MCM 15506 G) This often is reflected by an order from the surgeon that says “notify Dr. X of patient’s transfer to RNF” or perhaps a telephone call to place a patient on the hospitalist’s schedule. So what is “concurrent care”?
Concurrent Care
Concurrent care exists where services “more extensive than consultative services are rendered by more than one physician during a period of time” (MCM 2020E). Basically this means that more than one physician has primary responsibility for managing a portion of the patient’s care (concurrently) during the patient’s inpatient stay. For Medicare and other payers, this is considered appropriate when these “concurrent” services are “reasonable and necessary.”