EM Coding Alert

Question: We are a large group with all the physicians billing under the same tax ID. One of our physicians does procedures that none of the other doctors in our group are able to do. The scenario is: Another physician sees a patient in the hospital and decides that he needs one of these procedures that only one surgeon does and they call him in to consult. He sees the patient to determine that she indeed needs this procedure, does a complete work up, and then bills a consult on the same day the other physician is billing for either a consult or inpatient visit. Shouldn’t our physician get paid for his consult as well as the procedure when he performs it?

North Carolina Member

Answer: Yes, your physician who will perform the procedure can get paid for both the consultation using 99251-99255 (Inpatient consultation for a new or established patient…) and the procedure. He will have to back up the claim with excellent documentation though. The billing of the E/M service on the same day as a procedure will also require modifier 25 (Significant, separately identifiable evaluation and management service by the same  physician or other qualified health care professional on the same day of the procedure or other service).

Note: If the procedure has a 90-day global, you can use modifier 57 (Decision for surgery) on the consultation code.

The catch is that most payers will not pay this on the same day if both of the physicians are credentialed with the payer, have the same specialty, and bill under the same tax ID.

Good news: If the procedure that only the one physician can perform is a subspecialty, your claim will be fine. Without the ability to declare a subspecialty, you will most likely have to appeal with good documentation.

As you know, appeals can get expensive. What you get in appeal may not cover the cost of the consult. You need to consider your options to avoid losing  money. The best option might be to bill the highest value E/M service the documentation supports instead of trying to bill both services.

You can also consider how you credential your providers at the various payers. If the second physician is board certified in another specialty, it might be beneficial to recognize him for that specialty.