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99223 Specialist Consultant

Carlos Posted Tue 18th of October, 2016 12:04:11 PM
Humana Insurance denied our claim stating 99223 not payable for rendering provider specialist only payable to PCP/Admitting Provider our provider is a Pulmonary consultant specialist not the admitting and we billed CPT 99223 as initial hospital visit was done. We already know we can't use Consult codes 99251-99955 since this not payable as per Medicare guidelines. This is a Humana Medicare HMO. What can we do in this case?
SuperCoder Answered Wed 19th of October, 2016 01:27:19 AM

When a Medicare patient is admitted, and another physician provides a consultation for that patient, a situation may arise in which both the admitting physician and consulting physician report an initial inpatient service (e.g., 99221-99223). To differentiate between the two physicians’ services, and to prevent a claims denial for duplication of services, the admitting physician should append modifier AI Principal physician of record to the initial inpatient service code.

For example: A patient presents to the emergency department (ED) with chest pain. The ED physician evaluates the patient and codes an ED visit (99281-99285). He also requests a consult from a cardiologist. The cardiologist evaluates the patient and decides to admit him. The admitting cardiologist would report an initial hospital visit (99221-99223) with modifier AI appended.

If the patient also has uncontrolled diabetes, and the admitting physician (the cardiologist) requests a consult from an endocrinologist, the endocrinologist might also select an initial hospital visit code, depending on the level of service she provides, to report her consultation. But the endocrinologist would not append modifier AI because she is not the admitting physician overseeing the patient’s overall care.

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