Charles Posted Tue 12th of December, 2017 16:56:27 PM
We have been getting denials for pre-op clearance by the pcp under the consult codes. If submitted with the surgeons name as the referring provider they have been coming back paid. Is it appropriate to submit a consult code for pre-op clearance with the referring surgeon? Or should I skip the referring provider and just submit it as an office visit?
SuperCoder Answered Wed 13th of December, 2017 04:48:04 AM
If your insurance is Medicare, then it does not accept claims for either outpatient (99241-99245) or inpatient (99251-99255) consultations, and instead requires that services be billed with the most appropriate (non-consultation) E/M code.
Report outpatient E/M services with the appropriate Outpatient Services code (e.g., 99201-99215, or 99281-99285 for patients seen in the emergency department). The service must be supported by the key components of history, exam, and medical decision-making; or time, if counseling and/or coordination of care dominates the encounter. For example, a surgeon sees a new Medicare patient in the office for a consultation for another provider in the area. The surgeon will bill the consultation visit as a new patient visit at the appropriate level using 99201-99205. For instance, to report 99203 Office or other outpatient visit for the evaluation and management of a new patient, the physician would need to document—at a minimum—a detailed history, a detailed examination, and low-complexity MDM. Or, the physician may report 99203 if counseling and/or coordination of care comprise 50 percent or more of a visit lasting 30-44 minutes, and the content of the visit is properly documented. Inpatient consultations should be reported using the Initial Hospital Care code (99221-99223) for the initial evaluation, and a Subsequent Hospital Care code (99231-99233) for subsequent visits.
You can also go to the following link for further information:
Hope this helps!