Wiki Needing help with denial of 99222 vs consults

[mscramer]

When Our doctor sees a patient in the hospital at the request of the PCP, Our doctor is a Infectious Disease doctor. When we bill 99222 it is getting denied, I do not khow if another code to use for consultations for all insurance companies. What should i use or do i just have to bill 99233. They denied as more than one physiican saw the patient type of denial . IT seems that a specialist should get paid for the consult. Medicare for sure, BCBS, Aetna, Humana are following suit

 

[Orthocoderpgu]

When a doctor asks your doctor to see a patient, that is not a consultation. The word consultation should only be used when it's appropriate and the three "R"s of consultations are documented. Even then, Medicare and now many private insurance companies don't pay for consultation codes due to them being used incorrectly. There could be multiple reasons for your E/M being denied. If the principle physician is not using modifier -AI, that could be a reason for your denials. It could also come down to a credentialing issue as well. I agree that your doc should get paid.

 

[csperoni]

The CMS guidance is specifically to use initial 99221-99223 or subsequent 99231-99233 for inpt services that would have previously used consultation codes. CMS also issued the guidance for the principle physician to use -AI. https://codingintel.com/billing-inpatient-consultation-for-medicare-patients/
I have not seen any Medicare denials from my local carrier (NGS) when using 99221-99223 even if another physician also billed 99221-99223.

Commercial carriers may set their own rules regarding whether another physician may use the initial 99221-99223 codes or should use subsequent 99231-99233. I do know I have had claims deny for another physician billing initial. Depending on the carrier (and their own particular policy), I either appeal quoting the CMS guidelines or use an appropriate subsequent 99231-99233 code.

And I know orthocoderpgu is a sticker for this, but is 100% accurate that the word "consult" gets thrown about inaccurately. Physicians use it simply to mean another clinician wants them to see a patient, regardless of the medical coding definition of consult. For a medical coder, it should only be used when a service meets the 3 Rs (request, render, reply). It's inappropriate use and abuse for years, despite re-education is why CMS no longer acknowledges consult codes.