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Increasing revenues for non-Medicare patients for Spinal practices or for medical billing outsourcing companies dealing with medical billing for spinal surgeons is always important. While spinal practices are well aware that Medicare eliminated consultation codes effective January 1, 2010, the fact is that though many private payers may follow these Medicare’s rules, they are actually not obligated to adopt Medicare payment policies.

Medicare’s elimination of consultation codes resulted in the following changes:

  • Services previously billed using a CPT consultation code are billed using the most appropriate evaluation and management (E&M) code
  • All office consultations for Medicare patients have become a new or established patient
  • Office consultations for Medicare patients are considered emergency department visits if the patient is seen in the emergency department, which is an outpatient facility.
  • For inpatients, spine surgeons must code an initial hospital service code or a subsequent hospital care code in place of an inpatient consultation code, depending on the circumstances

Not billing for consults has lead to significant losses for many specialties including spine practices. According to a recent Healio report, Medicare payment changes:

  • Reduced payment for these office consults by 20% or more
  • Led to loss of inpatient consult revenue for Medicare patients
  • Introduced complexity in choosing code category (new, established, consultation, initial hospital care, etc)
  • Delayed claim submission and increased denials due to these complexities

The main reason why spine practice lost out on revenue is that they believed that these changes applied to both private and government payers. What spine surgeons should know is that as private insurance companies are not obligated to adopt Medicare’s payment policies, reporting consultations of non-Medicare patients can increase revenue. Consultation codes are also recognized by some Medicaid payers. Here are situations when billing a consultation code in a spine practice is justified:

  • A patient’s primary care physician refers a patient with back pain – possibly due to a herniated disc – to the spine surgeon
  • The emergency department (ED) physician requires the spine specialist to visit the ED to see a patient with a vertebral fracture from a fall
  • A hospitalist asks the spine specialist to see an inpatient with a pathological vertebral fracture

There are many reasons why opting for expert orthopedics medical billing services would be the right option for spine practices. Billing and coding experts in experienced companies would be knowledgeable about:

  • Which non-Medicare payers in the practice’s network pay for consultations
  • The correct Current Procedural Terminology (CPT) rules for consultation coding
  • Guidelines for reporting outpatient and inpatient consultations
  • Billing rules of non-Medicare payers
  • Established processes to capture consultation charges
  • Claim submission after review of the encounter

On their part, spine surgeons need to follow consultation documentation rules. They should document the consult on the electronic medical record encounter record for appropriate patients, and send a separate, patient-specific consultation report to the requesting physician.

As consult codes pay more, payers tend to scrutinize payment requests for consultations. With their extensive experience in the field of reporting consultation codes, a professional an orthopedics medical billing company can help spine specialists increase revenue and reduce denials.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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