Wiki Medicare / BCBS Initial Hospital Visits

[KByrd]

We have had a problem with our specialty providers when seeing a patient in the hospital as there initial visit. We bill Medicare Initial Hospital Codes / Inpatient Consultation codes, Medicare will pay but BCBS denies for only one initial visit per hospital say. How do you get paid from the secondary insurance BCBS?

 

[SharonCollachi]

In those instances, we don't bill an admission if we didn't admit the patient.

 

[csperoni]

This is a situation where CMS and CPT rules differ.
When CMS did away with consult codes, they advised what would have been a consult code to use initial inpatient. The admitting uses -AI modifier. Any other physicians, no modifier.
Some commercial carriers have a policy to only pay 1 initial visit code during the entire admission to admitting physician. Their policy is for any other physician that subsequent visit codes should be used, even though it may be your clinicians first time seeing the patient.
Some commercial carriers don't have an official policy, but may sometimes deny an additional initial visit code by a different physician/group.
From my experience, most carriers will follow CMS guidelines. If I know/realize in advance a carrier will only pay 1 initial regardless (and we are not admitting), I will bill subsequent. In absence of such a policy, I appeal explaining we are a different group/specialty and quote the CMS guidelines. If the carrier denies the appeal, I will then submit a corrected claim for subsequent visit.