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medicare and consult codes

  1. #1
    Default medicare and consult codes
    Exam Training Packages
    First let me say that I am well aware that Medicare quit paying for consult codes. My questions if that we had a pt with private insurance that is primary and we saw in consult, not realizing that she had a secondary of Medicare. THe private ins paid for the consult and it was forwarded on to Medicare. Medicare denied as they do not pay consults. Can I bill the member for the allowable or do I send payment back to primary Ins, rebill with new pt code and then on to Medicare? thank you for your help.

  2. #2
    Baltimore East, MD
    From the CMS website (

    Q. Will Medicare contractors accept the CPT consultation codes when
    Medicare is the secondary payer?

    A. Medicare will also no longer recognize the CPT consultation codes for
    purposes of determining Medicare secondary payments (MSP). In MSP
    cases, providers must bill an appropriate E/M code for the E/M services
    previously reported and paid using the CPT consultation codes. If the
    primary payer for the service continues to recognize CPT consultation
    codes for payment, providers billing for these services may either:

    • Bill the primary payer an E/M code that is appropriate for the service,
    and then report the amount actually paid by the primary payer, along
    with the same E/M code, to Medicare for determination of whether a
    payment is due; or

    • Bill the primary payer using a CPT consultation code that is
    appropriate for the service, and then report the amount actually paid
    by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is

  3. #3
    Thank you for your reply. That is what we did, we billed the primary insurance a consult code and then it went to Medicare. Medicare denied because of the consult code. Can I bill the patient ?

  4. #4
    Baltimore East, MD
    You shouldn't bill the patient. Review the documentation, and change the consultation code to the appropriate non-consult E/M for the service. Resubmit the claim to Medicare with the E/M code, and note the amount the primary insurance had paid on the original consult code.

    It may be easier if you submit the non-consult E/M to the primary insurance in the first place. You'll of course get lower reimbursement, but it will save time/money on backend work on the claims.

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