Medicare Consult Denials – Key Clarifications

by | Published on Sep 28, 2016 | Medical Billing

Medicare Consult Denials
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Starting January 1, 2010, Medicare stopped paying CPT procedure codes for consultation services CPT 99241-99245 – office or outpatient consultations and CPT 99251-99255 – inpatient initial consultations. A lot of confusion still prevails on the right codes to use for medical billing of specific services provided during the consultation. Here are some key clarifications on the matter:

  • For office or outpatient consultations, providers should follow regular E/M guidelines for outpatient services, and bill using 99201-99205 or established office/outpatient 99211-99215 visits. The service should be supported by the key components of history, exam, and medical decision-making (MDM)—or time, if significant counseling and/or coordination of care took place.
  • For inpatient consultations, physicians should bill services for Medicare patients as initial inpatient patient visits using 99221-99223.
  • The consultant can only bill one initial hospital care code (99221-99223) per beneficiary inpatient stay.
  • If the services provided do not meet the documentation requirements for the lowest level initial hospital visit (99221), CMS instructs the physician to report subsequent hospital care codes (99231-99233).
  • For consultation services provided to Medicare patients in the emergency room, physicians should use the emergency room (ER) services codes (99281-99285) according to the level of service provided and documented in the medical record.
  • If the Medicare patient is admitted to the hospital on the same day as the ER visit, the consultant should use the initial hospital visit codes (99221-99223) and not the ER services codes.
  • Physicians who provide consultation services while the patient is in observation status must use the appropriate outpatient service codes (99224-99226). For instance, if a patient is admitted with severe abdominal pain and the internist asks the gastroenterologist for an evaluation, gastroenterology medical billing should be for the appropriate outpatient service as the patient is receiving hospital outpatient observation services. Payment for an initial observation code is for all the services provided by the ordering physician on the date the patient’s observation services began.

Modifier AI also has to be used appropriately. Defined as Principal Physician of Record, the main aim of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. It should be used by the admitting or attending physician who oversees the patient’s care. Modifier AI has to be appended in addition to the initial visit code. All other physicians who perform an initial evaluation on the patient should report only the E/M code for the level of service they provide.

Appropriate medical documentation standards should be followed for consultation services billed to Medicare. The patient’s medical record should indicate the physician overseeing the patient’s care in the inpatient or nursing facility setting. The documentation in the hospital setting should communicate the results of an evaluation to the requesting provider and should include the order or documentation for the request and access to the consultant’s notes, which meet Medicare’s documentation requirements, and also medical necessity for the additional services.

Coding experts in professional medical billing and coding companies can ensure accurate coding and claim submission to meet Medicare guidelines, helping physicians optimize reimbursement for inpatient and outpatient consultation services.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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