Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist performed an inpatient consultation on a Medicare patient, and we billed 99253 for the visit. The documentation supported the level of service coded, but the claim was denied. Where did I go wrong?

Michigan Subscriber

Answer: Medicare stopped accepting CPT^® codes for consultation services (99241-99245 and 99251-99255) as of Jan. 1, 2010. When the Centers for Medicare and Medicaid Services (CMS) stopped paying for consults, it said it still recognized the concept of consults but paid for them using different categories of codes.

For inpatient consultations, Medicare requires providers to bill these services as initial inpatient visits (99221-99223) in lieu of codes 99251-99255. If the documentation doesn’t support the lowest-level initial hospital care code, you can use a subsequent hospital care code (99231-99233).

Remember: In order for the consulting physician to get reimbursed, the admitting physician must remember to append modifier AI (Principal physician of record) to the initial hospital visit code, so they are indicated as the admitting physician as opposed to a consulting physician.