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hospital Consult, with decision for surgery

Francisco Posted Tue 08th of November, 2011 14:31:52 PM

Our doctor was asked to consult on hospital patient 99223 for recurrent strep. I added 57 modifier to indicate the decision for a T&A the next day 42821. Insurance denied payment for consult stating it was a "subset procedure disallow" on procedure 99223.57 Do our doctors not get paid for the hospital consult in these cases?

SuperCoder Answered Tue 08th of November, 2011 14:34:01 PM

Check if CPT 99223 was already billed on the same day?

Francisco Posted Wed 09th of November, 2011 15:53:25 PM

No, not that I'm aware of. I have a couple more with the same circumstances. With the new CMS guidelines, Is there any way to code the initial EMS and get paid for the evaluation service when the decision for surgery (day of or day after) is the result of the consultation/evaluation? As it stands now, I am going through the appeals process, and still getting denials.

Francisco Posted Thu 17th of November, 2011 15:06:51 PM

We do many hospital consults, with needed surgeries the same day, or day after. We are getting a lot of denials. Is there a way to code the EMS 99223and get paid for the evaluation, and also the surgery that is a result of the consult? Most insurances are paying for the surgery, and denying the EMS.

SuperCoder Answered Thu 17th of November, 2011 16:11:35 PM

Have you used modifier 57 with the E/M code?

Francisco Posted Thu 17th of November, 2011 17:53:30 PM

Yes, on all of the EMS. Example: 99223 with 57 modifier.

Francisco Posted Tue 29th of November, 2011 14:25:11 PM

I have about six of these denials. Is there another option? Maybe a 25 modifier on the EMS?? The initial evaluation was necessary to determine the need for surgery. Please help!

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