Optometry Coding & Billing Alert

Published on Wed Jan 27, 2010 PDF

If you bill 99241-99255 to private payers, good luck getting Medicare secondary balance.

Don't even think about billing a consult to Medicare -- even if the claim is only a secondary payer claim.

Medicare may have scratched consultations off its list of payable services, but many other insurers did not follow suit. This leaves you in a quandary when your physician performs a consult and the primary insurer pays you for the service, but Medicare is the secondary payer.

The "Medicare Secondary Payer (MSP) will not pay for consults," says Samantha Daily, billing specialist with a practice in Portland, Ore. Recently published MLN Matters article MM6740 indicates the following:

"In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation ...]. If the primary payer for the service continues to recognize consultation codes," you should bill in one of the following two ways:

• Bill the primary payer an E/M code, and 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

• Bill the primary payer using a consult code, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

"The first option may be easier from a billing and claims processing perspective," indicates CMS in the MLN Matters article.

"There is essentially no workaround for this situation, so you have to decide whether you will get paid better via payment from the primary insurer with a consult code versus the alternative (billing an E/M to both payers)," says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Consulting located in West Chester, Penn.

Potential snag: In some cases, such as a physician seeing a hospital patient, the doctor may not know whether the patient is on Medicare or has a different insurer when he documents his consultation. Coders will need to be able to glean an appropriate E/M code from the physician's consult documentation if the patient ends up being on Medicare. "Medicare has created a genuine mess, and unfortunately there are providers who now have simply informed their staff that the physicians will no longer accept consult requests on Medicare patients, that if a Medicare patient is referred for a consult they're not available," Burleigh says.

To read the MLN Matters article on the consult elimination, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.