Wiki Nephrology coding question

[Shelli Morris]

Hello, I work at a Nephrology office - my MD's go to the hospital for rounds. When they do a consult they are billing 99222-99223 but they are also billing 90935-90937 (dialysis) I am putting a modifier 25 on the EM code and we are finding that that some insurances are only picking up the 90935 or 90937 and NOT the E/M. Can anyone help with getting the E/M also paid along with the procedure? We are getting paid for the dialysis only. Can anyone give any in site on what we are billing wrong? I thought about putting modifier 59 on the dialysis 90935. Any thoughts, ideas would be greatly appreciated.
Thanks
SM

 

[TThivierge]

Hi Shelli
There are outpt. and inpatient consults. Inpatient consults are CPT 99252- 99255 and outpatient consult CPT 99242 to 99245 to bill for commercial payers. Ensure documentation state it is consult, pre approved if possible and who referred from -which provider. Also add on claim if new or established patient for this consult. The codes you used above seem wrong try those suggested or subsequent inpt. visits if payer is Medicare...CPT 99231-99233. Medicare does not cover consult 99242 or 99252 sets. Modifier 25 seems correct since adding dialysis happening during same consult visit .
I hope this data helps you
Lady T