Wiki Primary and Secondary with different coding guidelines

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annawade13

annawade13

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Hello-

Does anyone have any advice about the best way to handle this situation? One example would be a patient who has BCBS primary and MC secondary. BCBS is billed with a consultation code and pays, but the claim gets hung up in the clearinghouse before making it to MC because of course MC won't pay on consultations. Will MC pay as secondary? SHould I send through as a denial? Should I change the code? Do I need to reverse and rebill BCBS with a level code?

Another example is labs- we don't send labwork to the government plans as primary because they have to be billed by the outside lab, but what about if the government plan is secondary to a commercial insurance that does pay providers for labwork?

There are times when commercial payers have special codes they prefer (S-codes, for instance) and I feel comfortable changing these, but when Medicare's concerned, I always like to get a second opinion. Thanks all!

:confused:
 
I have run across this, and even went to a second level appeal with medicare and still got a denial. Because I didn't know they had Medicare as a secondary we ended up just writing it off. The only way to have gotten it paid that I could come up with was to refund the Primary insurance, recode the consult charge, send a corrected claim and then bill Medicare. Really they wouldn't have picked up anything anyway.
 
Medicare will allow you to change the code from consult to whatever the documentation supports, this information was in the instructions Medicare published when they stopped accepting consutl codes. I've done this many times with no problem, however I clearly document what I'm doing, what the original consult code was and what code it's been changed to for submission to Medicare.

I don;t know about lab charges, I've never done lab coding.
 
Can you tell me the steps you took, I changed the codes and sent the orig EOB from the primary with a letter explaining and still got a denial. I would love to know if there was something else I could have done.
sandi
 
I agree with dclark7. I work for specialists and I always code the consult code (for a consult) when I bill private insurance. Then when the primary has paid and MCR, VA, or a MCR HMO is secondary I change the consult to the OV level appropriate to the documentation and send it. I have never had a problem with the charges being paid this way. And per what MCR published when they decided not to accept consult codes this is appropriate and entirely legal. I think they pretty much left it up to providers and their coding staffs as to whether they wanted to take the time to change the codes for a higher level of reimbursement or just accept the lesser payment from private insurance in these instances.
Of the "government" insurances only Medicaid still recognizes and pays the consult codes.
 
I see your reasoning for the OV's, but what about consults in the hospital setting. These are the ones I was talking about. I work for a PCP so we don't get consults very often.
Sandi
 
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