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replacement code for 99242

  1. Default replacement code for 99242
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    I need to know if there have been any replacement codes for consult 99242. Ins is saying this is not a valid code....Marilyn

  2. #2
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    You probably have an ins that is adopting Medicare's policy that consults are no longer valid services, so therefore the codes are not recognized. This was as of Jan 1 2010. The codes you use for office visits are regular New or established and for inpatient are the initial inpatient levels, using the 1995 or 1997 guidelines to determine the level.

    Debra A. Mitchell, MSPH, CPC-H

  3. Smile consult codes
    I need to know if there are a replacement code for consult code 99242. Insurance is
    saying this is an invalid code...marilyn

  4. #4
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    No there are no replacement codes. The code is not invalid, the service is, which then makes the code a not recognized code. There are no replacement codes. You must determine the patient type, new, established or inpatient, and then use the 95 or 97 guidelines to determine the level of service. 99201-99215 or 99221-99223. If the payer has adopted Medicare policy then you cannot bill consult codes.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    North Carolina
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    For Inpatient...99231/99232. I agree with Debra regarding the outpatient.


    Q. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?

    A. There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent
    hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

    Q. How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?

    A. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.

    http://www.cms.gov/MLNMattersArticle...ads/SE1010.pdf
    Last edited by RebeccaWoodward*; 11-29-2010 at 01:11 PM.

  6. #6
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    Ah I agree Rebecca, the 99242 would not match to the 99221-99223 levels. I was speaking generically and failed to notice the level of care referred to in the initial post. So it would be the 99231-99233 for the inpatient given the level 2 consult being asked for. Thank You.

    Debra A. Mitchell, MSPH, CPC-H

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