The Executive Suite: Medical Coding: Consult notes, hospital admit code disagreement, and video complexity vs time

Q1. Some insurance companies have started not paying us for consults when they request notes and they don’t see the CC statement showing that the requesting provider received a copy of the note.

What if we create a part of the EMR that says ‘a copy of this note is stored in a shared chart with the referring provider therefore a hard copy is not being sent’. And do you know if they are going to keep paying for these in 2021?

A1. Yes, one of the requirements for consults is that ‘the findings are documented in the patient’s medical record and communicated by written report’, and a payer could deny if they can’t see this element. But don’t assume that an automated and generic one liner as you’ve indicated above will necessarily meet the requirement.

There are several things to consider: 1) If this becomes ‘part of the EMR’, then it could easily end up being used on new patient and other visits and quickly become ‘wallpaper’ and somewhat meaningless since it’s on everything, and 2)–This would only work for MDs in the same group or in the same EMR, and 3) It’s generic – and they like specific – ‘by written report to the requesting physician’ - not just ‘stored in the EMR’.

They’d much rather see some specific reference to an action taken – that the note was sent, faxed, tasked, shared etc. with Dr. X – that’s part of what the extra payment associated with these is for. The idea that there is an EMR ‘solution’ to every requirement is part of the reason the notes have become so bloated – lot’s of generic disclaimers and references intended to ‘cover’ a multitude of requirements. But they don’t really.

This one-liner also has the ‘referring’ provider language – which doesn’t always mean a consult as we know. The best advice is to get rid of referring language and actually require your providers to at least ‘fill in the blanks’ on something – ‘This consult report has been made available in the EMR to Dr. X in response to their consult request.’ And we don’t want to see it on new patients!

As to your second question – Are consults still going to be paid? – this is pretty clearly in the hands of the private payers. The AMA’s CPT manual has continued with these codes for over ten years after Medicare and most governmental payers stopped paying them, but it seems that every passing year another major payer either drops them or tries to limit payment for them. I wouldn’t bet on them long-term, the payer trend seems to be steadily away from them.

Q2. Our coders have a disagreement about the use of the hospital admit codes. CMS states that more than one provider may bill Initial Hospital Care as long as they are of a different specialty and the billing diagnosis is different. I was also able to find reference to this same guidance in the AAPC Procedure Desk Reference. However, the CPT Code book continues to state that only the admitting provider may bill for those Initial Hospital codes and all others must bill Subsequent Hospital Care Codes. So which one is right?

A2. Good question, it would seem that the AMA and CMA are saying opposite things – but they are both right in their own way. It's just that AMA /CPT doesn't take into account CMS's payment policy of using the 99221-99223 codes to cover the inpatient consults that they don’t pay for. So AMA’s guidance is a coding rule that applies to those ‘initial hospital care’ codes in their intended use as ‘admit’ codes. What CMS is showing you is essentially a payment policy that as above really accounts for different specialists using the ‘admit’ codes to represent their initial inpatient consults. Sometimes it hard to sort out coding rules versus more billing or payment-oriented guidance.

Q3. Can you clarify the guidelines for coding 99213 vs 99214 on complexity vs time? After the COVID waiver to expand video visit coverage I was advised that billing for video visits was based strictly on time. I have certainly had some Level 4 visits based on complexity of decision making but that last less than 25 minutes needed for Level 4 based on time.

A3. So whether it's a Telehealth visit with audio/video or a face-to-face office visit, at least for the duration of the PHE either vector allows you to code by total time or by the level of medical decision-making (MDM) alone.

As you may know this is also how the codes 99202 - 99215 will work starting in 2021 - time or MDM. That time being the MD time (attending time) and that time including some pre and post encounter elements not previously included (such as the time it takes you to type your note).

Back in March/April CMS had announced these upcoming 2021 rules would be in effect during the PHE. At this point, as 2021 draws near, we really don't see them going back to the 'old' way, although this is possible.

So in your scenario above, those visits that had (documented) moderate decision-making could have been billed as 99214's based entirely on that without regard to time. The EM office visits code have never been set up to have time as the key determinant of a code level. They had only allowed using coding by time as an option when certain circumstances led to the time becoming the predominant character of the visit, trumping as it were the level of MDM.

It is the online codes 99421 – 99423 and the audio only telephone codes 99441 - 99443 that must be coded based on the time involved. Maybe that's what you were thinking of.