Consultation Services and Medicare as Secondary Payer: Tips for Billing

By Delly Parham, CPC, AS

Medicare rule changes make staying on top of collections one of a practice’s biggest challenges.

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For example, with the exception of telemedicine, Medicare has eliminated payment for consultation codes, while many non-Medicare payers continue payment for consultations using the CPT® consultation codes [99241-99245 (office/outpatient) and 99251-99255 (inpatient visits)]. This creates confusion over how to bill when a non-Medicare carrier is the primary payer and Medicare is the secondary payer. Here are some tips:

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  1. The consultation criteria must be met to report the consultation codes. The criteria include the “four Rs” (Request, Reason, Render, and Report).
  2. If the Primary payer follows Medicare’s Consultation rules, providers must bill an appropriate E/M code for the services instead of CPT® consultation codes: for example, 99203 instead of 99243.
  3. If the primary payer continues to recognize consultation codes described in the CPT® manual, you must first determine the reimbursement rate for the consultation code vs. the reimbursement rate for the E/M code. You may choose either of the two options described below. The option you choose could affect the amount of reimbursement depending on the circumstances.

    Option 1:
    Bill the primary payer using the outpatient (99201-99215) or inpatient (99221-99233 Initial and Subsequent Hospital Care) E/M codes just as Medicare requires. Then report the amount actually paid by the primary payer along with the same E/M code to Medicare for determination of whether a payment is due.

    OR

    Option 2:
    Bill the primary payer using a consultation code that is appropriate for the service. Then report the amount actually paid by the primary payer along with an E/M code appropriate for the service to Medicare for determination of whether a payment is due as secondary payer.

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