E/M Help

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My urologist was asked to see a patient in the NICU who had a circ an hour prior. Do I bill 99477 or how do I bill for this?
 

Tami_F

Guru
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Detroit
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My urologist was asked to see a patient in the NICU who had a circ an hour prior. Do I bill 99477 or how do I bill for this?
No. These intensive (and critical) care codes should only be billed by the attending service. Code to the documentation. Did your urologist perform the procedure? Was it a consult? If your urologist documented providing critical care, use the time based critical care codes (99291-2).
 
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So when I started at my job, we have always used subsequent hospital codes for inpatients instead of consult codes. Has anyone heard of this or is anyone else doing this?
 

mchaidez

Contributor
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Hi,

Yes, I work with internal Medicine Physicians and from time to time other specialists contact them for consults. Physician has to document that he was called for consult and reason why and complete full examination. Hope this helps

depending on Insurance, I usually use 99221-99223
 

Tami_F

Guru
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Detroit
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So when I started at my job, we have always used subsequent hospital codes for inpatients instead of consult codes. Has anyone heard of this or is anyone else doing this?
I have not heard of this practice. Do you know what the rationale is for coding consults this way?

It sounds like downcoding, and is almost certainly costing your practice both revenue and RVUs. The only reason I can think of for billing a sub day instead of an initial day is if the documentation doesn't meet the minimum requirements for 99221.
 

Pathos

True Blue
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658
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Beaverton OR
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I agree with Tami_F. In CMS opus, downcoding is just as bad as upcoding. We as coders are instructed to code based on medical documentation only. Like Tami, I am assuming that the reason for submitting a subsequent visit instead of consult, is:
  1. Payer doesn't accept consults, so -> Initial visit
  2. Documentation doesn't support Initial, so -> Subsequent visit
Anything beyond that is incorrect coding and could actually end up as a False Claim.

Hope this helps!
 

Pathos

True Blue
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658
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Beaverton OR
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Do you guys know what insurance companies do not pay for consult visits?
I don't have a complete list of insurances who does and does not pay for consultations, however this might be more of a trial and error method.
I do know some that do NOT accept consults, and you would have to then crosswalk to the next appropriate E/M code (New/Established patient). Here is a short list:

1) Pretty much any government entity. This means Medicare, Medicaid, VA, Tricare, etc.
2) I read somewhere that United Healthcare (UHC) will stop paying for consult codes with DOS of next week (10/1/2019).
3) BlueCross/BlueShield, and anyone in that family
4) Most MVA/Work Comp - I would call before billing to help prevent denials

The rest depend on your area and state. At my previous job, the coders had a running list of payers who paid and who didn't pay. You might consider starting one for your practice too?


Can you bill for the initial even if your own doctor wasn't the admitting doctor?
Can you give me an example of this? I look at the Initial visit much like a hospital New patient (for that hospital stay only), but the CPT book might have something else to say about that (don't have it handy right now).

Here is a pretty good article on the subject:

http://bulletin.facs.org/2013/02/coding-for-hospital-admission/

Hope this is helpful!
 
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I just saw this and you may have your answers by now but in case you are still looking - this is the list we go by:
United Health Care stopped accepting consults as of 6/1
Cigna stopped as of 10/1
Others that do not accept consult codes are: Medicare as Primary or Secondary, Medicare HMO, VA, Aetna, Workers Comp, UMR
If you have others, please send them along.
 

dja214

Networker
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33
Location
Lakeland, FL
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Can you bill for the initial even if your own doctor wasn't the admitting doctor?
For inpatient you can use 99221 - 99223 for initial visits or consults, as the admitting MD will use modifier AI with his/her initial. As far as OPPS only the admiting MD can use 99218 - 99220. You would have to use 99201-99205, 99241-99245. For subsequent visits you use 99212-99215 for OPPS.

Hope this helps you!
Deanna
 

pfwilliams39

Contributor
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Houston, TX
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I'm new to E/M coding. I code a lot of 99213 with injections 20610 and the medication. I was told to always add modifier 25 on the visit when coding for the injection, If there is only 1 dx code and the E/M and injection are related w/o a different dx is the correct?.
 

ahardy92

New
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Location
olive branch, MS
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Our practice has billed out like this as well, I was advised that that is correct, however some payers will deny stating e/m is inclusive to injection although Modifier 25 has been appended.
 
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Location
Duluth, GA
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Hello, I have a question pertaining to amount or complexity of data reviewed under the MDM section when selecting E&M. Does a provider need to document what was discussed when they note in the chart "discussed case with another healthcare provider: nurse and physician"?
 
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