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Medicare Consult Denials; Coding for Unusual Services


Our coding expert discusses what to do when Medicare denies a consult code; preparation for Medicare chart audits; and coding for unusual services.


Q: I have some questions relating to what we do to deal with Medicare not paying for consult codes. Please look at some scenarios below where I'm not sure how to bill.

First scenario: Patient A comes to the ER with an issue (say he has abdominal pains and fever) and he is admitted to observation status by the hospital, the attending hospitalist who sees the patient in the ER (Dr. X) codes the initial observation code - because he is the attending. Is this correct?

A: Yes - nothing ambiguous here. Use the initial observation codes if that is what you are doing. The only relevance the consults have here would be if the patient was not admitted. Then you'd have to use emergency department codes for the ER "consult." CPT guidance would suggest that you use office/other outpatient codes 99201-99215, but most Medicare administrative contractors suggest the ER codes 99281-99285.

Q: Second scenario: Dr. X (the internist) asks Dr. Y (consultant) to see the now observation patient about the potential surgical abdomen. What code does Dr. Y code? CPT says, "For observation encounters by other physicians, see office or other outpatient consult codes (99241-99245) or subsequent observation care codes (99224-99226) as appropriate." What it doesn't address is what to do if an observation code is not accepted by Medicare - which I think is what is confusing to the coders.

A: Part of what is throwing you off here is that you are reading the CPT manual and its instructions while thinking about Medicare coverage guidelines. CPT still recognizes consults, and so its guidance on re-admits and observation services hasn't changed.

Since the patient is an outpatient, and there is no code for an initial observation visit for a provider other than the admitting physician, you are now forced into the office/other outpatient code 99201-99215 code series because there is no other option.

CMS states (30.6.8) "Payment for an initial observation code is for all the care rendered by the ordering physician on the date the patient's observation services began. All other physicians who furnish consultations or additional evaluations or service while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service."


Q: When Medicare asks to see charts for some type of review, is there a way to know what the problem is?

A: There is no answer that covers all the possibilities, but the place to start is with the request. They will usually give you some type of reason for the review, a general category such as documentation, medical necessity, or a program such as CERT, MUE (medically unlikely edits), NCCI, or RAC.

If you are talking about a request for documentation review, you can tell a lot simply from the number of charts they request. A request for somewhere between five and 15 charts is often just a probe sample. There is no specific target or issue of interest, it may be just a general audit to determine if there is a problem with documentation, coding, or other current issues of concern.

When the number of charts requested gets somewhere in the range of 15 to 50, then it is pretty certain that the payer has some specific target - an idea that some type of infraction has occurred or is occurring - and they want to get some sense of frequency or severity.

If a sample is between 50 and a 100 charts, it is likely that someone on the payer end has a pretty clear idea of what the infraction may be, and is seeking a statistically valid sample possibly to begin calculating damages or repayments.

So in a sense you can tell something about a problem from the request. More related to the scope of the problem than the exact subject. And don't forget to call and simply ask.


Q: What are the most common and acceptable codes I can use to complement my normal "visit" codes? I hear about all kinds of other codes, but don't want to do anything that will either burden my patients or cause a problem with insurance companies.

A: There are a number of CPT codes, some newer, some older, that providers can use to represent either unusual or certain specific circumstances or services. Find below some of the more standard services and a brief description of each.

Advanced care planning

99497 is for the discussion of advance care planning "first 30 minutes," and may include filling out forms, discussions with family and the patient. It can be billed on the same day as an E&M visit or [Annual Wellness Visit]. If billed with another E&M put a modifier 33 on it so the patient has no copay or deductible.

99498 is an add-on code when the encounter goes beyond 45 minutes. For both codes you must document the time spent, 16 minutes is enough for 99497 alone.

Transitional care management services

Including communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge. As of Jan. 1, 2016 you can bill these on the date that you saw the patient for the included E&M visit. Bill this instead of the traditional 99214 hospital follow-up if requirements are met.

99495 - Transitional care management services with the following requirements:

Medical decision making of at least moderate complexity during the service period and face-to-face visit, within 14 calendar days of discharge.

99496 -Transitional care management services with the following requirements:

Medical decision making of high complexity during the service period and face-to-face visit, within seven calendar days of discharge.

Smoking cessation counseling

Document the time spent and counseling content:

99406 – Smoking cessation counseling, three minutes to 10 minutes

99407 - Smoking cessation counseling, over 10 minutes

And don't forget the prolonged services codes 99354 and 99355. I'm sure you have encounters that go beyond the normal visit length. Once you go 30 minutes beyond the "typical" time (25 minutes for a 99214) and document the content of the additional time, you are entitled to the 99354 in addition to the basic service.

And when you get a chance, look into the 99490 chronic care management services. This is a little more involved than the codes above, it requires some logistical elements to be in place - such as access to EHR - but it pays well and your older patients may appreciate the security of knowing you are keeping more of an eye on them.

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at billdacey@msn.com. He will help clear up the confusion.

This article was originally published in the May 2016 issue of Physicians Practice.

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