How to bill for hospital consults without physical exam

What is the best way to charge for a consult at the hospital that does not require a significant physical exam? For example, I was asked to see an old Medicare patient of mine who was in urinary retention following a major surgery. My billing department told me that I could not charge without documenting a physical exam.

You have asked a very important question for urologists. First and foremost, your billing department is correct. A Level 1 initial hospital care code requires a detailed physical exam (at least four exam points for the affected organ system, in this case the genitourinary system, and at least four exam points in other organ systems).

Without the required history and physical exam, we recommend using the subsequent hospital care code that is satisfied by your documentation for the visit. Some medical directors have recommended using an unlisted evaluation/management code; however, this method of reporting is much more problematic and should be pursued only if required by the payer.

For future consults that do not require a significant amount of physical exam, we recommend considering charging by time, if over 50% of the time has been spent in counseling the patient and coordinating care. Charging by time in the hospital includes the total time spent on the floor, talking to the nurse, reviewing the chart, discussing the issue with the patient, taking a history, performing the medically necessary physical exam documenting the encounter, etc. Three things should be recorded in the chart:

  • specific total time indicating the time spent with the patient, and the floor time as indicated above
  • time spent in counseling the patient or include the statement that “over 50% of the time was spent in counseling and coordinating care”
  • issues/data discussed with the patient.

The average time to accomplish a Level 1 recorded in the CPT book is 30 minutes. This is considered an average time and not a “threshold” time. If you spend less than 30 minutes, you can still charge this code (99221).