Inpatient Consults

[Dansk2011]

Curious as to if inpatient consults are worthwhile from a time/monetary standpoint. Is it possible to make a decent living doing primarily consults. Obviously depends on the amount you are doing per day but from a time perspective would it be worth it and if so how many a day would you need to do for it to be profitable without killing yourself. Is it similar to a reasonable inpatient census? A lot more hospitals are looking to build out a consult service line and I don't do any currently nor have I done any in a while.

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[DMBandFan86]

I assume it is similar for billing as there are a lot of people doing inpatient rehab as a consulting model. Which seems to be similarly profitable as being primary service. The billing codes for consult are different, at least on first day service. Would think you need more than 15 patients per day to make it worthwhile.

I am also interested to know. I do some inpatient consults, but don’t do routine follow ups on them so I am not familiar with the billing. What do you bill for follow ups, is it the same as if you were primary? Is there a collection difference for IPR if you are a consultant model vs primary model?

 

[Iamnew2]

Curious as to if inpatient consults are worthwhile from a time/monetary standpoint. Is it possible to make a decent living doing primarily consults. Obviously depends on the amount you are doing per day but from a time perspective would it be worth it and if so how many a day would you need to do for it to be profitable without killing yourself. Is it similar to a reasonable inpatient census? A lot more hospitals are looking to build out a consult service line and I don't do any currently nor have I done any in a while.

Like with everything it depends - do you mean consults as in you are the consulting doc in a unit and medicine is admitting? Generally that is a profitable model. If you mean just going and doing consults at hospitals would likely be challenging - I would say you’d need like 15 a day which would be unlikely unless you are following them but it’s unlikely you’d follow that many people at one facility. It would require multiple facilities to get to that number. My former group had a pseudo set up where they divided up the patients and one doc did the consults along w seeing some inpatients. Consults alone outside of a daily following of those patients and a large number of them is likely challenging.

 

[RangerBob]

If you mean acute care consults you can make good money, but it's more work than seeing patients on a rehab unit, where the patients are "fish in a barrel" for lack of better words. Plus, acute care patients are more likely to be uninsured/not met their deductible, so reimbursement per unit of time worked may be lower. On the other hand, you're not having to field phone calls from nursing, and really don't need to take call (aside from accepting consults), so that might make the lower reimbursement rates worthwhile. You can usually justify following up on many consult patients at least once or twice, which also helps. In fact, if you offer to do peer-to-peers for the primary group, you'll become everyone's BFF. So often PTP's now are done by the acute care team (at request of insurance company), presumably because the primary team just wants the patient off their service/doesn't understand the true benefits of acute rehab. So they're more likely to get denied.

I think a great practice is one where, say, three docs rotate, with say two on acute rehab and the other doing consults at any given time, or all three doing a hybrid mix of consults/acute rehab, and admitting the patients they consulted on originally, which makes for great continuity of care.

 

[Momentum70]

I'm not sure if I have met anyone that solely did that. At a few places including the one I work now, all the physiatrists have their own acute rehab inpatient service and will see consults at the acute care hospital associated with us on as needed basis. I typically find these great as if I recommend IPR and they admit then my H&P is pretty much done except for whatever updated since I saw them for consult. The key is writing your consult like an admission H&P

 

[Iamnew2]

I'm not sure if I have met anyone that solely did that. At a few places including the one I work now, all the physiatrists have their own acute rehab inpatient service and will see consults at the acute care hospital associated with us on as needed basis. I typically find these great as if I recommend IPR and they admit then my H&P is pretty much done except for whatever updated since I saw them for consult. The key is writing your consult like an admission H&P

Sorry to piggy back on this thread but my question is - is it possible to have an acute rehab facility (IRF) with no PM&R doctors? One of our sister hospitals advertised for like 2 years and counting for a PM&R physician, they couldn't get anyone. So they hired a medicine doctor and that medicine doctor sees all patients, I think with a midlevel. No PM&R doctor sees patients. They "Credentialed" this person as a "rehab" doctor.
Is this legal?

 

[DMBandFan86]

Yes, you need a rehab physician to follow Medicare guidelines. Does not have to be PM&R. They have to meet certain vague standards and experience to qualify as a rehab physician. Again, has to be a physician.

 

[Iamnew2]

Yes, you need a rehab physician to follow Medicare guidelines. Does not have to be PM&R. They have to meet certain vague standards and experience to qualify as a rehab physician. Again, has to be a physician.

What kind of requirements are needed? The hospital just made all the medicine doctors "rehab physicians." this seems super shady to me.

 

[DMBandFan86]

“1. Clarification regarding the qualifications of the rehabilitation physician.

The rehabilitation physician is a licensed physician (not necessarily a salaried employee of the IRF) who has specialized training and experience in rehabilitation. It is the responsibility of each IRF to ensure that the rehabilitation physicians that are making the admission decisions and caring for patients are appropriately trained and qualified. While the IRF must continue to meet the hospital conditions of participation specified in 42 Code of Federal Regulations §482.22 regarding documentation of staff qualifications, we do not require specific documentation in the patient’s medical record to demonstrate the rehabilitation physician’s qualifications.”

 

[Momentum70]

What kind of requirements are needed? The hospital just made all the medicine doctors "rehab physicians." this seems super shady to me.

I know they recently updated these requirements because we recently hired someone to help cover weekends that was IM. They had to have a certain amount of experience (i think 2 year) working in a rehab setting although this could include SNF. And there was also 20-30 hours of specific CME they had to complete. When we hired someone about a year ago to also help on weekends, the CME component was not required.

 

[lejeunesage]

It depends on what exactly you're doing in these consults.
The easiest inpatient consults are where you go see the patients to determine whether they're a good candidate for IPR. It's basically what you would have done in residency if you had a consult service.
You're focused on:
1. Good fit for IPR vs SNF
2. Current barriers to admission.

Insofar as you make recommendations, it's to manage things that might be an impediment to participation in therapy. For instance, you might recommend changes in their analgesic regimen to improve their participation/performance in PT.

Super simple stuff. Insofar as you're adding value, you might be able to save an IPR unit from admitting an inappropriate patient (assuming they care) or you might help a patient slated for a SNF discharge where they'd get few therapy hours rerouted to an IPR admission.

It's possible to do this job without any connection to an IPR: get yourself credentialed at one or more hospitals as an independent contractor, working closely with case management teams to improve throughput, but it would be a precarious position:
- You'd be seen as replaceable by case managers and clinical liaisons.
- If you don't have access to an IPR or SNF where you or your group can admit these patients, your value is lessened. Hospitals only care if you can help them get these patients off the floor and out the door.
- If this is your only/main revenue stream, your life will be easy, all it would take is for a case manager, surgeon, or hospital administrator to decide to stop consulting you because they don't consider that you're adding any value and you'd be screwed.

Your best bet if you're going to do inpatient consults is to:
1. Be an admitting physician at an inpatient rehab unit. There's a big difference between saying "this patient would make an excellent candidate for IPR admission" and "I will admit this patient to my unit today/tomorrow."
2. Try to add value other than just "IPR vs SNF." You won't be able to do this in every case, but can you help with medication management for impulsivity, agitation or sleep-cycle optimization in brain injury patients? Can you make recommendations to surgeons who don't care to manage that stuff but haven't consulted IM regarding lab abnormalities/BP issues that are a barrier to IPR admission?

As for the pay, it's similar to inpatient billing. Your main codes will be 99223/99222 and 99232. Depending on the insurance mix where you consult, the results might or might not be impressive. If you work in a ritzy suburb where you primarily see rich people with commercial insurance, you'll do well. If you work in a place with a high Medicaid population, you won't make much. If memory serves, MediCal (Medicaid in CA) pays something like 40% the Medicare rate. You won't retire rich on that kind of income.

Assuming you only see Medicare patients, and you focus on only Medicare patients are you're able to see 5 new consults a day + 5 return visits, you'll bill about $1350.
The trick is being able to get those new consults. 5 new consults (that's where the money is) per day isn't that easy to get in most hospitals. If you're aiming for more, you might need to split your time between 2 or 3 hospitals.

If you're able to see something like 8 new consults a day a bill 99223, you're looking at about $1600 in billings per day, which is not bad at all. Still, if this is your only revenue stream, you're always going to have some anxiety about whether the consults will keep on coming.
If you do the combined IPR + consult route, once you get your efficiency up (it came after a few years for me) and hire a scribe, it's relatively easy if census allows to see 20 patients and have all the charting + conferences done in 5 hours. After that, assuming your rehab unit is attached to your acute care hospital, it's super easy to go to the neuro/ortho/surgical floor and do some consults. Even if you can add 2 new 99223 charges per work day (about $400 at the Medicare rate), you'll be very happy at the end of the month.

 

[Dansk2011]

Figured I'd ask this question in this thread. If you see a consult for IPR placement in the hospital and the ARU is located (not attached but actually a floor in the hospital) in the same hospital as the consult, are you then able to bill for an H&P when they are eventually admitted to the unit? My colleagues were under the impression that you would write an H&P but would have to bill as a progress note/follow up as they were already seen by someone in the same practice/group within the hospital despite being different settings, albeit essentially same location. I've asked the hospital billers but have not gotten an answer as of yet.

 

[Momentum70]

Figured I'd ask this question in this thread. If you see a consult for IPR placement in the hospital and the ARU is located (not attached but actually a floor in the hospital) in the same hospital as the consult, are you then able to bill for an H&P when they are eventually admitted to the unit? My colleagues were under the impression that you would write an H&P but would have to bill as a progress note/follow up as they were already seen by someone in the same practice/group within the hospital despite being different settings, albeit essentially same location. I've asked the hospital billers but have not gotten an answer as of yet.

I dont want to say 100% because I am not sure your place has some weird exception or rule, but yes you can bill a full consult and a full H&P and I have done this myself many times. Even if they share some of the same property, like a unit in the hospital, they are most likely their own "hospital" Its why you cant do transfer orders like you would moving someone from ICU to the basic neuro unit. The acute IRF should have their own medicare numbers and other qualifiers that make them different. Another way to tell is to look at your credentialing. I had to be credentialed to do consults at the Acute hospital which included all floors including basic, ICU, step down, etc. I also had to be credentialed to see patients in the LTAC which was just a unit in the hospital, and I had to be credentialed to see patients in the IRF. They said it had to do with all 3 being their own separate units. Hope this helps

 

[Dansk2011]

I dont want to say 100% because I am not sure your place has some weird exception or rule, but yes you can bill a full consult and a full H&P and I have done this myself many times. Even if they share some of the same property, like a unit in the hospital, they are most likely their own "hospital" Its why you cant do transfer orders like you would moving someone from ICU to the basic neuro unit. The acute IRF should have their own medicare numbers and other qualifiers that make them different. Another way to tell is to look at your credentialing. I had to be credentialed to do consults at the Acute hospital which included all floors including basic, ICU, step down, etc. I also had to be credentialed to see patients in the LTAC which was just a unit in the hospital, and I had to be credentialed to see patients in the IRF. They said it had to do with all 3 being their own separate units. Hope this helps

Thank you. Much appreciated.

 

[lejeunesage]

I dont want to say 100% because I am not sure your place has some weird exception or rule, but yes you can bill a full consult and a full H&P and I have done this myself many times. Even if they share some of the same property, like a unit in the hospital, they are most likely their own "hospital" Its why you cant do transfer orders like you would moving someone from ICU to the basic neuro unit. The acute IRF should have their own medicare numbers and other qualifiers that make them different. Another way to tell is to look at your credentialing. I had to be credentialed to do consults at the Acute hospital which included all floors including basic, ICU, step down, etc. I also had to be credentialed to see patients in the LTAC which was just a unit in the hospital, and I had to be credentialed to see patients in the IRF. They said it had to do with all 3 being their own separate units. Hope this helps

This is my understanding as well.

 

[Dansk2011]

Are you billing initial consult codes or typically inpatient initial codes for the first consult? I'm being told that Medicare/Medicaid will not cover consult codes but some commercial insurances will. Thanks.

 

[lejeunesage]

I bill 99223 or 99222 for initial consults.