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Modifier for 99253 with 2 consults from 2 different specialists

  1. #1
    Default Modifier for 99253 with 2 consults from 2 different specialists
    Medical Coding Books
    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
    Hi Heather
    This depends whether the GI surgeon did any procedures on the same day with the consultation.if he had done so the consultation is inlucded in the surgial package. If the consult was done based on desecion for surgery 57 modifier may be used on the consult code.

    Correct me if i am wrong!!!!


  3. #3

    You are absolutely correct. The 2 specialists both provided professional opinions/consults and no procedures were performed by either, which is why we are questioning the General Surgeon getting paid and the GI not.


  4. #4
    Sorry Heather

    I think only one E/M consult can be billed per day.


  5. #5
    Richardson, Texas
    Make sure you are reporting the two consults with different diagnosis codes. If both the general surgeon and GI specialist are reporting their services with the same diagnosis or condition, the carrier will see this as one service.
    Linda Hallstrom, CPC, CPMA, CPC-I, CEMC
    Richardson, TX AAPC Chapter

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