Modifier for 99253 with 2 consults from 2 different specialists

erthsvr

Networker
Messages
28
Best answers
0
I have a dilemma with a commercial insurance carrier in regards to a denial we keep receiving for 2 different specialists providing consults on the same day. I work for a Multi-Specialty Group and we had a General Surgeon and a Gastroenterologist perform consults on the same day. The General Surgeon has been paid, the denials all revolve around the GI Specialist. At first the insurance carrier denied the GI doc as a "duplicate" charge. We appealed with consultatoin notes from the hospital and this time we received a denial stating that we need to "submit a revised claim form with the accurate modifier information."

We can not figure out what modifier the carrier may be asking for and they are not offering any suggestions. After doing some research on the internet, I have very few reliable sources. The one I did find suggested using HCPCS modifier AF - Specialty Physician.

Does anyone have any suggestions?

Thanks,
Heather MacPherson, LPN, CPC, CPC-H
 

reach2helen

Contributor
Messages
14
Best answers
0
Hi Heather
This depends whether the GI surgeon did any procedures on the same day with the consultation.if he had done so the consultation is inlucded in the surgial package. If the consult was done based on desecion for surgery 57 modifier may be used on the consult code.

Correct me if i am wrong!!!!

Helen
 

erthsvr

Networker
Messages
28
Best answers
0
Helen,

You are absolutely correct. The 2 specialists both provided professional opinions/consults and no procedures were performed by either, which is why we are questioning the General Surgeon getting paid and the GI not.

Thanks :)
 

lhallstrom

Guru
Local Chapter Officer
Messages
174
Location
Chandler, Arizona
Best answers
0
Make sure you are reporting the two consults with different diagnosis codes. If both the general surgeon and GI specialist are reporting their services with the same diagnosis or condition, the carrier will see this as one service.
 

MELJOHN72

New
Messages
1
Location
ARCADIA, CA
Best answers
0
Anthem BC of CA is denying Inpt consultation code 99253. The denial stated "We covered this care as part of another service". I called the customer service dept for Calpers, the representative told me another physician had already been paid for this code on the same day. She also said it was a different specialty. She said she could not send the claim back I would have to appeal. I sent appeal and explained the other provider who was paid was not in our group and was a different specialty I explained our general surgeon was called in to see patient for epigastric pain and sent them copy of his report. They denied with message "Reimbursement is not allowed for face to face medical consultations billed with Inpatient or office consultation procedure codes. Consultations should be reported with the appropriated new or established evaluation and management cpt code that describes the services provided". What code are they talking about? Cpt 99202-99205 are for out-patient or office place of service. This was a new patient so I can not bill 99231-99233. Is anyone else having this problem with Anthem? Does anyone have suggestion on what code they will accept?
Thank You
 
Top