If you are talking about inpatient consult codes 99251-99255, I will note 2 things:
1) A consult from a coding perspective has a very particular definition (3Rs) and most requests from another healthcare provider do not meet this coding definition.
2) Medicare (and now almost all other commercial carriers) will no longer pay for consult codes.
So few accept them that we don't even bother going through the process of determining if it meets the definition of consult and whether or not the carrier accepts them and no longer code them.
When Medicare stopped acknowledging consult codes, CMS advised to use 99221-99223 instead. The guidance further advised the principal physician of record to use -AI modifier. From
https://www.cms.gov/outreach-and-ed...k-mln/mlnmattersarticles/downloads/MM6740.pdf:
"In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT code 99221 – 99223) or nursing facility care visit code (CPT 99304 – 99306), where appropriate."
This is specifically Medicare guidance. This is one of the rare situations where CPT guidance and CMS guidance do not line up 100%.
Some carriers follow the CMS guidance and permit multiple physicians to use the initial inpatient hospital 99221-99223. Other carriers will only pay 1 physician for the initial code. All other physicians (even different specialties, different practices, or meeting the coding definition of consult) must bill using inpatient followup 99231-99233.
Your tactic to fight the refund is to first determine whether they follow CMS guidance. If they do, send them the CMS guidance. If they do not, you should submit corrected claims from 99231-99233 and ask for the refund request be pended until the corrected claims are processed to determine the correct refund amount (which should be much less than they are currently requesting back).
Good luck!
