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cons vs 99223

Paula Posted Thu 27th of May, 2010 13:37:18 PM

What would you do if Anthem is primary and MR secondary use 99244 for Anthem and 99204 for Medicare?

Melanie Answered Thu 27th of May, 2010 13:39:35 PM

Always review your documentation, the time-structure of the code... they dont always transpose over cleanly....

Teresa Answered Thu 27th of May, 2010 13:43:08 PM

I would use 99204 because we have found in our clinic that if you use the consult code and Anthem pays and the claim goes to Medicare they will deny it and then you have to change the code and we had to send to Medicare Review Department with documentation before we had payment on any of our claims. We have just found it is easier to bill as a New Patient and not have to deal with all the hassle of trying to get Medicare to pay. I am sure it will not be long before all commercial carriers will follow Medicare. I hope this helps.

SuperCoder Answered Thu 27th of May, 2010 14:26:54 PM

This is a Medicare MSP situation. Medicare may have scratched consultations off its list of payable services, but not all insurers followed suit. This leaves you in a quandary when your physician performs a consult and the primary insurer pays you for the service, but Medicare is the secondary payer.

You can use following tips to handle the situation:

The Medicare Secondary Payer (MSP) will not pay for consults. In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation ...]. If the primary payer for the service continues to recognize consultation codes, you should bill in one of the following two ways:

• Bill the primary payer an E/M code, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due.

• Bill the primary payer using a consult code, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether apayment is due.

The first option may be easier from a billing and claims processing perspective, according to CMS.

The SuperCoder E/M SURVIVAL GUIDE and other guides have explained these kind of situations in excellent detail.

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