Author Topic: Consultation Codes Denial  (Read 541 times)

skhakoo

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Consultation Codes Denial
« on: June 19, 2021, 01:39:30 PM »
I work for a Neurologist office.  We are experiencing high number of consult claims with CPT codes (99221 - 99223).  Insurances such as Horizon BCBSNJ, Aetna and Amerigroup deny the claims and provide one of the following denial codes:
a).  The number of Days or Units of Service exceeds our acceptable maximum. 

Other denials provide the following denial codes:
a).  Payment denied when performed/billed by this type of provider and this provider type/provider specialty may not bill this service.

I have been billing CPT code 99221-99223 for long time and I am stumped.  This is the only Neurologist in this office (a solo-practitioner).  We are billing 99221-99223 with # of units of 1.  CPT 99221-99223 is used only once in the claim.  It does not matter whether we are using 99221 or 99222 or 99223 - i have seen issues with all of these.

Is anyone else experiencing this issue?
How do i get around it?

THanks.
Shabbir

kristin

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Re: Consultation Codes Denial
« Reply #1 on: June 19, 2021, 03:45:53 PM »
The codes you listed are IP Initial visit codes. Is the neurologist the doctor that is admitting the patient to the hospital?

If not, those codes cannot be billed by the neurologist, they can only be billed by the admitting doctor. That is why you are seeing those denials, because the admitting doctor already billed the same code for the patient.

You have to bill IP Subsequent codes instead: 99231-99233

skhakoo

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Re: Consultation Codes Denial
« Reply #2 on: June 20, 2021, 09:02:01 PM »
Thanks Kristin for your response.  So two things:
a).  The Neurologist is not the admitting physician. 
b).  The way I am reading your response is that if a specialist is not an admitting physician, then there is NO way for this specialist to be reimbursed for the initial consultation service.  In other words, unless you are an admitting physician, initial hospital care service codes 99221-99223 are simply not allowed for any physician.  Unfortunately, this is counter to my understanding.  Per CMS guidance "CLM104c12", which Chapter 12 of Medicare Claims Processing Manual, section 30.6.10 talks about Consultation Services and no way in this section is this limitation that CPT codes 99221-99223 is only intended for Admitting physician.  Section 30.6.9.1 bullet G specifically talks about "Initial Hospital Care Visits by Two Different MDs or DOs when they are involved in same Admission".  The guidance here is straight forward and it states "In the inpatient hospital setting all physicians (and qualified nonphysician ...) who perform an initial evaluation may bill the initial hospital care codes (99221-99223)".  It further talks about modifier AI to identify the Principal physician of Record. 

It is therefore my understanding that if a patient is admitted by a PCP, and the PCP then subsequently calls in consultation to a Neurologist and Cardiologist, the correct billing would be:
PCP - 99221-99223 with modifier AI
Neurologist - 99221-99223 without any modifier
Cardiologist - 99221 - 99223 without any modifier

Is my understanding incorrect? 

Thanks.

Michele

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Re: Consultation Codes Denial
« Reply #3 on: June 20, 2021, 09:44:23 PM »
My understanding is the same as Kristin's.  I have only seen plans allow one admission code per inpatient stay.  It may be that is how it is supposed to be coded, but it may not be allowed by the insurance plans. 
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Re: Consultation Codes Denial
« Reply #3 on: June 20, 2021, 09:44:23 PM »