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billing issues with specility

Aida Posted Fri 31st of August, 2012 20:33:24 PM

I work in a group of multi specility, we have OB-GYN, Hospitalist, Infectious disease, Family Practice and Endo.

Now how will this affect our billing if the Infectious Disease was call in for a consult by one of our hospitalist on the same day.

We do bill with the same tax ID, and Group NPI.

SuperCoder Answered Fri 31st of August, 2012 21:14:07 PM

The first step is to see if the payer is accepting consults as a valid service.
Second if you can bill as a consult then be sure to have the 3 Rs met. Having the medical record does not satisfy the R requirement for report. It must be a formal dictated letter of consult which is kept in the medical record as well. If it is truely a referral then there is no consult. A referral is where a provider knows what the problem is and does not feel it is in their area of expertise so the patient is "referred" to a provider that can better treat for the condition. A referral cannot be billed as a consult. A consult is where the provider does not know what the problem is and is asking (Request) another specialist for help to provide opinions or answers (Render) to what the problem is and provide the letter of consult (Report) back to the requesting provider which contains all the information on what was found. All 3 Rs must be met for a consult to be billed.

Doesn't matter that they have same tax id. If a specialty is not within the scope of practice of the referring physician this is a true referral. Today there are many multi specialty groups billing under the same tax id. As long as the 3rs are satisfied this is truly a consult. The physician must also be set up as a specialist with all insurenace plans. Most multi specialty groups do this.

Most commercial insurers are still paying on consults. They do not pay consults on medicare advanatage plans. In the northeast this includes blue cross and united healthcare. Not to bill a consult is a loss of revenue.

P.s. Billing a new patient code for a specialist in a multi specialty group under the same tax id is a loss of income. If you can bill a new patient then you can certainly bill a consult (again 3 rs need to be satisfied). The only difference is the loss of income for the reimbursement between the two codes.

Source: AAPC

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