CMS’s Refusal to Pay Consults Makes MSP Claims a Headache
Posted on 12. Jan, 2010 by Editor in Hot Coding Topics
If you bill consults to private payers, good luck collecting the balance from Medicare secondary payers.
Don’t even think about billing a consult to Medicare — even if it’s only a secondary payer claim. Medicare may have scratched consultations off of its list of payable services, but many other insurers did not follow suit. This leaves you in a quandary when your physician performs a consult and the primary insurer pays you for it, but Medicare is the secondary payer.
“Medicare Secondary Payer (MSP) will not pay for consults,” says Samantha Daily, billing specialist with Urologic Consultants, PC in Portland, Ore. She points coders toward MLN Matters article MM6740, which indicates the following:
“In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes. 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; or
• 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 a payment is due.
CMS indicates in the MLN Matters article that “the first option may be easier from a billing and claims processing perspective.” “There’s essentially no workaround to this situation, so you have to decide whether you will get paid better via payment from the primary insurer with a consult code versus the alternative (billing an E/M to both payers),” says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Consulting...
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HEATHER, CPC
13. Jan, 2010
There is another facet to this change as well. Previously if you were called upon to manage a portion of a patient’s care during a hospital stay, your initial visit with the patient may not have been a consult, it may have been a subsequent care code. It is my understanding now that any physician who sees a patient for the first time during an in-patient admission can now bill a initial hospital care code as long as someone else of the same specialty from their own practice has not already treated the patient during that admission (providing they meet the minimum documentation requirements for that code). I even asked about when a patient is admitted by another MD over the weekend from a different practice and my MD (who is the primary) comes in on Monday and takes over their care, and according to the NGS presenter yesterday, when my MD comes in Monday and assumes that patient’s care, since it is his first encounter with that patient during that admission and since he is from a different practice, he can bill an initial care code. Does anyone have any conflicting information concerning this?
Jan Allen
13. Jan, 2010
I can’t help but think CMS does this on purpose to avoid making payments. I’m thinking about copying this article and sending it to my county’s congressman and my state’s senators. Maybe we should ALL bombard our “employees” (congress and the senate DO work for us) and tell them what we think: CMS gets some hair-brained ideas! And who ARE the CMS employees who think up this stuff… let’s see some names so we can send THEM letters of complaint!
Elvira G. Santos
13. Jan, 2010
I’m pretty sure not only MSP getting headache of the not paying the consult but also billing company like us. If we bill the primary insurance and our provider got paid from the primary payer for the consult code then we will be ending up writing-off the difference/coins. portion and this will be a huge adjustment or decrease of both our revenue. For every code assigned for each claim including consulation , payment must be always based on medical necessity of the service done. If payer’s judgement of the claim is not necessary then , denied the claim. I think each provdiers just need to be educated on E/M coding if they don’t understand then they shoould hire a certifed coder who will educate or code for their services.
Sheila Carson
13. Jan, 2010
Is the MSP issue really that big a deal since Medicare’s allowable is always less than a Commercial payors allowable and we don’t get a secondary payment in this case anyway?
Torrey Kim, CPC
14. Jan, 2010
Heather, it sounds like you heard correctly. The doctor who is considered the attending physician will append modifier AI to his claim to show that he is the attending, and all other physicians who see a patient for the first time in the hospital can bill the initial hospital care code, this is a new change…see the following:
“In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221-99223) or nursing facility care codes (99304-99306),” according to CMS Transmittal 1875, issued on Dec. 14.
“As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day,” the transmittal reads. “Modifier AI … shall be used by the admitting or attending physician who oversees the patient’s care.”
Best,
Torrey Kim, CPC
Editor-in-Chief
Part B Insider
torrey@partbinsider.com