Wiki Medicare is sec and doesn't pay consult codes

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ChristieH

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Help..when MC is sec ins, how do we get them to process the consult code (for which they no longer allow) that was billed and paid by the pri ins carrier. For example, CPT 99254....BCBS/UHC/Aetna....all allow this consult code and MC does not. Do I just change it to a Medicare allowed code such as the new patient code....do I call the clerical reopen line and ask them to corect the CPT code after the claim has been denied by MC...what do you all do in your practices when this situation occurs? Thank you for any suggestions.
 
The article says that we bill the consult for the commercial and after we get paid change the code to E/M, submit to medicare. Does that mean we can bill two different codes for the same service in a single claim?
 
Not necessarily. First, you submit the appropriate consult CPT code to the commercial payer. When you receive their EOB, then you would need to re-code the chart, change the consult code to the appropriate E&M code and submit the claim to Medicare for consideration. This can be an administrative nightmare. If any type of Medicare policy is involved at all, I suggest billing a straight E&M service. This works for our office and requires a lot less work.
 
knimmer said:
Not necessarily. First, you submit the appropriate consult CPT code to the commercial payer. When you receive their EOB, then you would need to re-code the chart, change the consult code to the appropriate E&M code and submit the claim to Medicare for consideration. This can be an administrative nightmare. If any type of Medicare policy is involved at all, I suggest billing a straight E&M service. This works for our office and requires a lot less work.
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Totally agree. I avoid the administrative nightmare by simply coding the primary with the E/M code that Medicare will accept. Many private insurers follow Medicare's lead, and you often find that those private insurers ALSO won't pay on 99254/99255.
 
I do change the CPT code when I submit to Medicare secondary. Usually most clearing houses will kick the claim back due to Medicare not accepting consults which gives you the chance to change the code then and not actually filing and getting a denial.
 
Thanks for your input

I appreciate your responses because this has been bugging me for awhile. So we will just need to pay closer attention and change the code before we submit to Medicare. Have a great week everybody.
 
If primary pays more on the consult than Medicare allows, why bill to Mcare as secondary? It is a catch 22 that I used to run into with commercial insurances and Medicaid as secondary or tertiary. Commercial plan states to collect copay, but Medicaid would not cover stating primary paid more than the Medicaid allowable.
 
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