Wiki 2 Separate Physicians billing on the same day

Create Wiki
S

s7mich@hotmail.com

Guest
Messages
26
Best answers
0
I have a patient that was transferred from a different hospital to us and then we saw the patient for a consult but not for the initial H&P. Another physician saw her for the initial H&P. My claim is now not getting paid because of this. Should I be charging an Eval code instead of a sub visit and is there a modifier that can be used so I can get paid
 
The physician that performed the initial encounter must append the AI modifier to their visit level for you to get paid. You need to use initial inpatient visit level with no modifier.
 
The physician who did the H&P would use the Initial Observation code (99218-99220)and your doctor would use an Office/Other outpatient visit code(99201-99215) if Medicare or an outpatient consult code (99241-99245) if the insurance accepts consult codes
 
@ dclark7 I must correct you.... according to CMS guidelines, if the pt was seen by the provider in the ED, you must bill the appropriate ED code. If pt is seen in observation, bill obs. If seen inpatient, bill inpatient. The ONLY time a dr can bill a outpatient/office location E/M 99201-99205 or 99212-99215 series is if the provider told the patient to meet him at the ED at the hospital and the patient is not actually "triaged and placed in a bed in ER dept." This is the official Medicare guidelines, not my opinion....
I actually read today that RAC audits are focusing on E/M codes, specifically they are looking at the location of the hospital the patient was in and comparing it to the E/M code billed.
 
@teresabug, the original poster said nothing about seeing the patient in the ED (otherwise I would agree with you regarding the ED code), it was stated that this was observation and according to the Medicare Claims Processing Manual Chapter 12 Section 30.6.8 (copied and pasted directly from the IOM):
"Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes."
 
teresabug said:
@ dclark7 I must correct you.... according to CMS guidelines, if the pt was seen by the provider in the ED, you must bill the appropriate ED code. If pt is seen in observation, bill obs. If seen inpatient, bill inpatient. The ONLY time a dr can bill a outpatient/office location E/M 99201-99205 or 99212-99215 series is if the provider told the patient to meet him at the ED at the hospital and the patient is not actually "triaged and placed in a bed in ER dept." This is the official Medicare guidelines, not my opinion....
I actually read today that RAC audits are focusing on E/M codes, specifically they are looking at the location of the hospital the patient was in and comparing it to the E/M code billed.
Click to expand...

dclark7 is correct. If this is a patient in Observation, only the admitting and attending physician would use the observation codes. Any other physician who is performing a consult would use the Outpatient codes for Medicare patients and a consult code for those insurances that still recognize the consult codes. I have attached a link to a decision tree that I refer to for the correct coding of consults for Medicare patients in either the office or hospital - maybe it would be helpful!

http://www.emuniversity.com/Consultalgo.pdf

Thanks!
 
You must log in or register to reply here.
Top