Internal Medicine Coding Alert

Answer: The carrier may be denying your claim because your documentation did not meet the criteria for 99255 or because you used the modifier incorrectly.

To use the initial inpatient consultation code 99255, you must have extensive documentation. The physician must note the following key components in the medical record: a comprehensive history (detailed history of present illness, complete review of symptoms, and complete past family social history), a comprehensive examination, and medical decision-making of high complexity. In addition, your documentation must include key information. This information is sometimes referred to as the three R's: the request for a consultation, the rendering of an opinion or advice regarding evaluation and/or management of a specific problem, and the report from the consultant. If you meet all of these documentation requirements, then you can code 99255, being sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). This is the correct modifier because it shows that the internist performed a separately identifiable E/M service on the same date as a procedure.

Use 92960 (Cardioversion, elective, electrical conversion of arrhythmia; external) for the cardioversion. It has a global period of zero days. The physician should dictate a separate report for the cardioversion.

If the encounter met all of the above documentation requirements and you used the correct codes and modifier, then you may want to appeal this claim.