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Thread: Consult codes with Medicare as secondary.

  1. #1

    Default Consult codes with Medicare as secondary.

    We are billing consult codes to the primary insurance when Medicare is secondary. With Medicare not paying the consult codes how are you billing in these situations. Do you bill the consult or convert it and what do you use for a reference to convert them?

  2. #2
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    We re-code them based on the E&M guidelines. I do have a crosswalk that I've attached, but they're based on NHIC's (the carrier for New England) guidelines.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3


    Thank you for the information.

  4. #4
    Join Date
    Apr 2007
    Everett, WA


    Pam, as usual, you helped me out too. Thanks for sharing!
    Suzanne E. Byrum CPC

  5. #5
    Join Date
    Apr 2007
    Scranton, PA


    We had this question come up in our practice recently and used this guidance from CMS:

    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 due.

    In our case we have found that if it is known ahead of time that the claim will be an MSP claim that billing the appropriate E&M to the primary payer is easiest. In the event that we billed a consult for an MSP claim unknowingly then we have had to take the second route and convert the consult to an E&M after the fact while revising our system to reflect the new charge and payments from the primary payer before billing Medicare.

    I hope this is helpful.
    Last edited by gibsona; 10-24-2012 at 07:25 AM.

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