Wiki 99221-99223 denials

mamon

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We had a claim for 99222 that was denied by Aetna since another provider had billed for it first. We are the attending physician (and was the one who asked for a consult with the other provider) so I appended the modifier -AI, sent in the corrected claim with reconsideration form but they still denied it. They are claiming that the code can only be billed once per day.

I checked again and CMS guidelines say that it can be paid to different physicians provided that they are responsible for different aspects of care/are in different specialties and are billing under different groups, which is the case for us, supported by our medical records.

We have had claims with Aetna Medicare with the same issue overturned before, but this is a commercial policy, and I'm a bit at a loss at what my next step should be. I would be grateful for any suggestions.
 
Is your office a PCP? We have this issue if we ask for a consult and than we use the same dx code that they would use. Insurance sees it as a duplicate and usually pays the specialty i.e. cardiology treating a cardiac issue. We usually have to have the provider review the note to make sure the correct dx code was used.
 
We've also had these denials because the plan isn't seeing that the other provider is of a different specialty. Once we point this out, they're able to confirm and reprocess our claims.
 
Is your office a PCP? We have this issue if we ask for a consult and than we use the same dx code that they would use. Insurance sees it as a duplicate and usually pays the specialty i.e. cardiology treating a cardiac issue. We usually have to have the provider review the note to make sure the correct dx code was used.

Thank you! I would check ours, that might just be it.

We've also had these denials because the plan isn't seeing that the other provider is of a different specialty. Once we point this out, they're able to confirm and reprocess our claims.

Unfortunately, pointing it out to them made no difference. :( We did that over the phone and also on the reconsideration form we sent in, but they still denied it. I've had luck with Aetna Medicare, but so far none with the commercial side. Thank you for your time~
 
Ugh. Sorry that didn't work for you. We've not had a good track record with them on other claims issues so I hope you have better luck than we have :)
 
Our office is also getting these. We are a cardiac surgeons office and a lot of our patients are TAVR's and are required to have a cardiologist and a cardiac surgeon sometimes this happens on the same day. Whomever gets the claim out first they pay. This just started happening
 
we started getting these same denials last year. We are neurosurgery so we are rarely the admitting provider. I seems that the commercial carriers did an update on their E&M policies and will only allow those codes for the admitting. We have been having to bill the subsequent visit codes because more carriers are no longer accepting consult codes. Per the CPT book any Initial inpatient encounter by a provider other than the admitting are to be reported as a consult code(99251-99255) or subsequent visits(99231-99233).
 
I spoke to a BCBS’s rep and he suggested to bill instead of 99221 99222 or 99223 as an initial consult to bill 99231 99232 or 99233 subsequent visit because they are paying the first claim that they received with the initial consult Only ONE for Pt’s admission .And also Rep said don’t submit medical records to make an appeal because BCBS is going to deny the claim again. I believe that this is unfair, I am not agree w the Ins.
 
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