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Consult billing...

  1. Default Consult billing...
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    My surgeon is consulted in the ER to evaluate pt for upper abd. pain and plans to take
    the patient to the OR for a EGD. Can I bill the appropriate consult w/mod 25 same day as
    the procedure? More important will Medicare pay for both the same day?

  2. #2
    Location
    Covington, LA
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    Yes, you would need a modifier 25 on the E&M code. Remember consults aren't covered by Medicare so you will have to bill a new or established patient outpatient E&M code since the patient was seen in the ED setting. As long as the physician's documentation supports seeing the patient and performing the procedure, the insurance company will pay for it.

  3. #3
    Location
    Columbia, MO
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    12,569
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    Quote Originally Posted by aclements View Post
    Yes, you would need a modifier 25 on the E&M code. Remember consults aren't covered by Medicare so you will have to bill a new or established patient outpatient E&M code since the patient was seen in the ED setting. As long as the physician's documentation supports seeing the patient and performing the procedure, the insurance company will pay for it.
    If the ER physician requested your physician to see the patient in the ER the you need to use ER visit levels (99281-99285) with ER POS. Not new or established patient levels.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Covington, LA
    Posts
    89
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    You need to be careful billing the ED codes 99281-99285, Some insurances will not pay for these codes when billed by two different physicans. The ED physician will only be able to bill code series 99281-99285 while the specialists has options.

  5. #5
    Location
    Columbia, MO
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    It is stated per CMS policy that the specialist must use the ER codes if the Er physician requests them to see the patient. transmittal 1875 December 14 2009 CR 6740, page 11 bottom of the page.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    I agree with the 9928_ codes for the ER for a Medicare patient. Just wondering if the 57 (decision for surgery) modifier could be used instead of the 25? We tend to use 57 in those instances when we turn around and take a patient to the OR

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