Anesthesia Coding Alert

Check out these 4 areas if you're getting denials A patient comes to your pain management practice for a consultation, but things get more complicated when the physician's assessment leads to a treatment during the same visit. You know it's sometimes appropriate to separately bill the consult and procedure, but you want to verify details before filing the claim this way. A discussion fresh from the Anesthesia & Pain Management Coding Alert listserv can help you avoid some common pitfalls when coding this situation.
 
The scenario: When a pain management physician sees a patient for a consult and then a pain management procedure results from the consult findings, can we bill Medicare for both services? We appended modifier -25 to the claim, but Medicare denied it.
 
If this sounds as if some of the claims carriers are kicking back to you, read on for our experts' advice on ways to trace the root of the problem. Ensure That It's a Consult It may seem elementary, but your first step is to verify that the encounter qualifies as a consult, not a standard patient visit. How can you tell? By checking for the four R's of consultations:
  a formal request - in writing - from the surgeon asking your physician to perform a consult
  documentation in the patient's chart of the reason for the consult and the opinion being sought
  review of the patient and the circumstances
  render an opinion about the patient's situation, and share that opinion in writing with the requesting physician. If the visit qualifies as a consult, report the appropriate code from 99241-99245 for an office or other outpatient consultation for a new or established patient; report 99251-99255 for an initial inpatient consult.
 
If the visit does not meet the "Four R's" criteria, it's not a consult. Instead, you report it as a new patient or follow-up visit, depending on the circumstances. This includes E/M codes 99202-99205 for a new patient office or outpatient visit or 99212-99215 for an established patient visit.
 
Caution: "Be careful when the report reads 'referred for nerve block' or similar wording," says Margaret Lamb, RHIT, CPC, an anesthesia coder with Great Falls Clinic in Great Falls, Mont. "This is just stating for the physician to do the procedure (which means the need for the block has already been determined) and send the patient back. It doesn't indicate a request for an opinion." Append the Correct Modifier If you're able to bill the consult with the procedure, you'll need a modifier to distinguish the two services. Appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is typically [...]