NAMAS Webinar Q&A: The In’s and Out’s of Consults, 04/06/2021

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, The In’s and Out’s of Consults: A Discussion on the Confusion of Consult Services in the Inpatient and Outpatient Place of Service, originally presented on April 6, 2021. These questions have been answered by the webinar presenter, Shannon DeConda, CPC, CPMA, CEMA, CMSCS

Question 1:
I too have billed for Pain Management. We were told by a previous auditor that when a patient is sent for a specific injection and was performed at the initial visit, we cannot bill any office visit. Even if the provider performed a full evaluation at the time of service. Is that Correct?
Answer 1:
According to the bundling edits, there is no bundling edit that exist between a new patient visit code and office based pain management injections that require a 25 modifier. Therefore, the answer is YES you absolutely CAN bill the office visit. There is no reason they cannot bill for the New Patient visit-- NOT a consult, but YES a new patient visit.

Question 2:
Example three would be a consultation right?
Answer 2:

Question 3:
If in a preop clearance the provider compares x rays to determine if patient is good to go for the surgery?
Answer 3:
I'm not sure what the question is here, but the key is to make sure that the there is an opinion. For example, the patient does have a comorbidity that does require clearance by primary care.

Question 4:
I understand about pre-op consult provided by a PCP especially when there are chronic issues. How about a consult service for a post-op like for pain management after surgery then subsequently managing it for instead of the surgeon.
Answer 4:
That is an interesting example. I am not sure I want to touch that one (haha) as that is co-management, but I will say that anytime that a provider's opinion is requested by another provider- it is a consult.

Question 5:
If ED provider requests consult of orthopedics for suspected fracture. And orthopedic physician provides consult and treats fracture . Can we bill consult for the initial visit
Answer 5:
The ED doc is NEVER asking for another providers opinion- and I failed to mention this example during our session (sigh). The ED provider is having ortho take on the care of that patient- not asking for their opinion.

Question 6:
The Psychiatrist is asking for medical clearance from on Internal Med MD ,to examine the patient, if they have any medical issues before the patient being admitted to the Psychiatric Unit. Some cases, the patient only have mental health issues. They bill a consult or the codes are being converted to other E&M code, however, the only dx what we can use is Z00.00 or Z00.8. These claims are being denied as no medical necessity. Any advise how to fight this claims?
Answer 6:
I have had this issue in other situations. Realistically, this visit is being done per hospital protocol at this point and not based on medical necessity as based on the point there isn't even a reportable diagnosis code. It is hard to give you a reason to appeal these because there really isn't a justifiable medical reason for these patients to be seen by internal med.
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