Internal Medicine Coding Alert

Published on Thu May 04, 2006 PDF

Experts walk you through solving a Medicare 99252-SNF payment problem

The next time Medicare rejects a preoperative consultation, don't just sit there and scratch your head. Try this solution.
 
Faced with a confusing denial for an E/M visit-place of service (POS) mismatch, one real-world coder turned to Internal Medicine Coding Alert for help. Two auditors show you how to tackle a denied claim from start to finish.
 
Case study: "Our doctor saw his patient in a skilled nursing facility (SNF) for a pre-op exam to clear her for impending orthopedic surgery," writes Jennifer Harward, coder at Colchester Internal Medicine LLC. Harward submitted to her Medicare carrier the following codes:

• CPT: 99252 -- Initial inpatient consultation for a new or established patient ...

• ICD-9: V72.84 -- Preoperative examination, unspecified

• ICD-9: 427.31 -- Cardiac dysrhythmias; atrial fibrillation

• POS: 31 -- Skilled nursing facility.

Problem: After denying claims that used the SNF information as the ailment to support the POS and the surgeon's information as the ailment to support the consultation code, Medicare said 99252 coverage required POS 21 (Inpatient hospital). Before you pursue payment or amend the submission, experts recommend that you take these actions:

Step 1: Read CPT's Consultation Location Policy

To see if 99252 makes sense with POS 31, consult your coding manual. "CPT breaks consultation into two series: inpatient, and outpatient or other," says P. Lynn Sallings, CPC, compliance officer for Family Medical Center, Area Health Education Center-Northwest in Fayetteville, Ark. For outpatient or other consults, you should use 99241-99245. When your internist performs an inpatient consult, use 99251-99254.
 
Several patient types fall under 99251-99254 including SNF patients. You should use inpatient consultation codes "to report physician consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting," states the initial inpatient consultation introductory notes. "According to CPT, 99252 is right with a POS of 31," Sallings says.
  
Action: "You should appeal your claim to Medicare citing the CPT guidelines," says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va. "You may want to attach a copy of the guidelines from your CPT 2006 book."

Step 2: Offer More Concrete Pre-op Reason

Preoperative exam payment problems more often stem from a lack of medical necessity than from the POS code. Medicare covers a preoperative consultation if the exam meets the medical-necessity guidelines, Pride says.
 
Best practice: "Check your local carrier's guidelines on billing for preoperative examinations," Pride says. They may have specific diagnosis and/or documentation requirements. In Harward's case, the carrier may have denied 99252 because V72.84 does not clearly define why the patient requires preoperative clearance.
 
Remedy: Consider using a more specific pre-op diagnosis code. "If the internist is clearing the patient for surgery because of the atrial fibrillation, the appropriate diagnosis code is V72.81 (Preoperative examination, cardiovascular)," Pride says.

Step 3: Verify That the Record Supports 99252

Make sure the medical record supports a consultation (e.g., 99252) as opposed to an SNF visit (such as 99308, Subsequent nursing facility care, per day, for the evaluation and management of a patient ...).
 
"Documentation must meet the definition of a consultation," says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP in Fort Lauderdale, Fla. The medical record must identify a consult's three R's -- request for opinion (in both the requesting and rendering physician's medical records, according to the new Medicare guideline), rendering of findings, and report back to the requesting physician, he says.