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Thread: M/Care consults when TMHP or Comm 2nd

  1. #1

    Question M/Care consults when TMHP or Comm 2nd

    AAPC: Back to School
    I would like to hear how other organizations are handling the new rule on Medicare consults when:

    Commercial Payer and/or Medicaid is secondary - they still accept the consult codes and should they receive more than one initial admission on the same DOS they are going to deny it.

    When the 835 files I am not sure if there is a process to stop these to change the code or if that is even appropriate.

  2. #2
    Join Date
    Apr 2007
    Burling, MA


    Based on the two options Medicare presented when a secondary carrier accepts the consult code and Medicare does not... I opted for billing the accepted Medicare code. I found it more cost effective to bill the code Medicare accepts and let it go thru to the 2nd carrier.
    More and more insurance companies will not accept a handwritten change/correction on a claim so there is so much extra time and cost invested. In other instances, certain claims crossover from Medicare automatically and then you are dealing with that correction.
    What I am recommending to doctors is to be more specific about their time with a patient so that they can bill ethically. For example, smoking cessation counseling, 50% of E/M visit counseling, prolonged service, overlooked procedures. Often, they lump everything into a consult when there is so much more. Fortunately, access to EMR documentation helps ensure coding is accurate.
    I am finding out through trial and error, as well as reading every carrier newlsetter that crosses my desk, that payers are slowly beginning to follow Medicare's guidelines. So be careful.

  3. #3
    Join Date
    Apr 2007
    Sioux Falls South Dakota


    We are billing the accepted Medicare codes to the secondary also. So far we haven't had a problem - but give it time with inpatient (office doesn't worry me much, but IP with the multiple initial visits sure does)
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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