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2 Inpatient Consults by 2 different Specialties

  1. #1
    Default 2 Inpatient Consults by 2 different Specialties
    Clearnace Sale
    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?

    Heather MacPherson, LPN, CPC, CPC-H

  2. #2
    Milwaukee WI
    Default Modifier 25
    Could they be looking for modifier 25?

    F Tessa Bartels, CPC, CEMC

  3. #3
    Richardson, Texas
    Default 2 consults, different specialists, same DOS & tax ID
    Double check the diagnosis codes before you resubmit the claim. If both specialists are reporting services for the same condition or diagnosis, the carrier will see this as one service.
    Linda Hallstrom, CPC, CPMA, CPC-I, CEMC
    Richardson, TX AAPC Chapter

  4. #4

    We had thought about a -25, but since the modifier states the "same" physician, we decided against it as they are 2 different physicians with 2 different specialties. The insurance company is vague: Their direct quote is: "Please submit a revised claim form with the accurate modifier information."


    The diagnosis codes that the physician used who didn't get paid, were 573.3 - Hepatits, unspecified and 787.01 - Nausea with vomiting

    The diagnosis codes the physician used who did get paid were 789.00 - Abdominal Pain, unspecified site and 782.4 - Jaundice, unspecified, not of newborn

    We are stuck as to what they are actually looking for. Thanks for your replies


  5. #5
    Milwaukee WI
    Default CPT vs Insurance
    I realize that per CPT the modifier -25 is not correct. But I'm wondering if it is what the Insurance Company wants on the claim.

    F Tessa Bartels, CPC, CEMC

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