# Commercial Insurance vs Medicare



## tinaval (Aug 18, 2011)

I was wondering how other offices are handling this situation;

When there is a commercial insurance that pay for consult codes but they have Medicare as secondary which we know don't. Per Medicare instructions, they said we can rebill the claim to a valid E/M code but leave the billed amount the same as what we billed to primary. Now we are told by our director to not bill consult codes to any insurance when Medicare is secondary because there may be fraudulent issues. Our Medicare F/U person is going to call Medicare again to reconfirm that's how they want us to handle these, but my question is, how do other office handle these?

Any help would be appreciated.


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## tpontillo (Aug 18, 2011)

I have been denied by Medicare when we billed the consult code.  We know have the billers change the code if they see that Medicare is secondary.


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## dclark7 (Aug 18, 2011)

We bill the consult to the primary insurance and then change the code to the appropriate (new or esablished) code prior to billing medicare.  We overirde the amount so that it's the same as the orginal charge amount.  This is all documented on the cclaim so that if anyone looks at it down the road they can tell exactly what was done.  Since this is how medicare wants the claims billed there should not be any questions of fraud as long as everything is documented.


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## btadlock1 (Aug 18, 2011)

tinaval said:


> I was wondering how other offices are handling this situation;
> 
> When there is a commercial insurance that pay for consult codes but they have Medicare as secondary which we know don't. Per Medicare instructions, they said we can rebill the claim to a valid E/M code but leave the billed amount the same as what we billed to primary. Now we are told by our director to not bill consult codes to any insurance when Medicare is secondary because there may be fraudulent issues. Our Medicare F/U person is going to call Medicare again to reconfirm that's how they want us to handle these, but my question is, how do other office handle these?
> 
> Any help would be appreciated.



Changing the code is a hassle, but if your MAC will accept it that way (with a mis-matched primary EOB), then you should be okay doing it. What we do in situations like this, is generally follow the primary payer's coding guidelines. Since you've got commercial as primary, I'm assuming that their COB allows payment for most of the charge, but if that's not the case (eg, they're applying a lot to deductible/coinsurance), then you're probably better off billing a higher-level office/outpt code from the beginning, to save time and effort. 

Your office is a specialty clinic, I assume? Don't forget that for consultations to truly be considered "consultations", you must have a documented request for your doc's opinion from an appropriate source (not the patient or their family), and your provider should be sending a written report of his findings/recommendations back to the requesting MD/other source. If the doctor's going through all of that work and he _knows_ it's a Medicare patient, he should also document his time and the extra effort spent in the visit, and writing the report, so that there's a chance he could code the visit based on time. (As long as 50% of the visit is dominated by counseling/Coordination of care, he can do that.) You might also be able to justify billing a prolonged service code (99354/99355 for face2face, or 99356/99357 w/o face2face), or 99080 (special report), to be compensated for the doc's extra time and effort, should you choose to avoid consult codes altogether. 

If you decide not to use consult codes at all, it's not really because of a_ fraud _concern, but a _convenience_ concern. It's probably going to be a lot easier to bill it one way and stick with it, especially for the small difference in reimbursement. I would suggest developing one plan and sticking with it, though, whatever you decide to do. Medicare's consult rules make more sense than CPT's - it would have been nice if they would have just changed the rules across the board, instead of leaving CPT's complicated instructions in place to confuse everyone, in situations like this. But that's just my two cents...

Hope that helps!


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