Wiki Anthem Commercial Policy of Wisconsin Consultation Codes

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kguzikowski

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Muskego, Wisconsin
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Most Recently our office has been sent several recoupment notification from Anthem Blue Cross Blue Shield. The notices state an overpayment exists and Anthem is requesting a refund.
The reason for the Refund is "Incorrect Billing was submitted resulting in a overpayment".
Per our call to Anthem, it was stated that the wrong code was billed. The pattern appears to we billed 99222, 99223 and they are now asking that the monies be returned as this is an overpayment.
Is Anthem looking for us to bill Consultation codes 99251, 99252, and 99253? Has anyone else experienced this?
 
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CPT guidelines indicate these services are reported only by the admitting/supervising provider; all other providers should report 99231-99233 or 99251-99255. Medicare and some payers may allow providers of different specialties to report initial hospital services and require the admitting/supervising provider to append modifier AI. For subsequent inpatient care, see 99231-99233. For discharge from an inpatient stay on a different date of service than the admission, see 99238-99239. For patients admitted and discharged from observation or inpatient status on the same date, see 99234-99236.

That's the info pulled from Encoder Pro. It might just be that it's not being billed under the right provider? Your best bet though might be to reach out to an Anthem rep directly and have them do a review of this claim.
 
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I didn't think Anthem was accepting codes 99251-99255, this maybe for the Medicare Products Only. Our call to Anthem resulted in a general statement basically use a different code. Reaching out to Anthem at least here on our
end can be a difficult task in itself. So if you have any tips and or tricks that would be useful I would appreciate any feedback. Just to receive the answer above at least 20 minutes on the phone.
 
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kguzikowski said:
I didn't think Anthem was accepting codes 99251-99255, this maybe for the Medicare Products Only. Our call to Anthem resulted in a general statement basically use a different code. Reaching out to Anthem at least here on our
end can be a difficult task in itself. So if you have any tips and or tricks that would be useful I would appreciate any feedback. Just to receive the answer above at least 20 minutes on the phone.
Click to expand...
I found this info:
It also mentioned
"In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation CPT codes 99251-99255 for the initial consultation service. The initial inpatient consultation is reported only once per consultant per patient per facility admission."

It seems like they are accepting that code but it's highly specific on how it's reimburse-able. That's just my 2 cents
 
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