Medicare Compliance & Reimbursement

Crackdown may hit your subspecialty consults extra hard.

Heads up: You may be seeing a wave of denials when your cardiologist sends a patient to an electrophysiologist for an extra consult. Learn how to fight those denials below.

For the past year, carriers have been cracking down on consult billing, say billing experts--and cardiologists and their sub-specialties have been especially hard hit.

The scenario: A cardiologist sees a patient in the hospital for a consult. The cardiologist passes the patient onto a colleague, an electrophysiologist, for another consult on arrhythmia or some other electrophysiologic problem.

The problem: Carriers have been denying the second consult because they believe electrophysiologists are cardiologists, and thus these are two consults by the same specialty. In fact, electrophysiologists are a sub-specialty of cardiology, and they deal with different areas, says Jim Collins with Compliant MD in Matthews, NC. Electrophysiologists are registered as cardiologists when they enroll in Medicare.

These denials aren't new, but they've become more frequent in the past year or so, say billers. Medicare is more reluctant to pay for two consults in the hospital, but especially not if the consults appear to be from the same specialty.

Hang tough: If you receive one of these denials you should work through the appeal process, and chances are you'll get paid, says Anne Karl, coding and compliance specialist with St. Paul Heart Clinic in St. Paul, MN.
 
Tip: Make sure the cardiologist and electrophysiologist use different diagnosis codes wherever possible. For example, the cardiologist may be seeing the patient for coronary artery disease, says Collins. Meanwhile, the electrophysiologist may see the same patient for atrial fibrillation, tachycardia or syncopy.

Another hint: Some carriers have advised coders to use the 77 modifier (repeat procedure) on the second consult.

Lately, though, the carriers have been making it hard to bill a second consult during the same hospital stay, even once you convince them the cardiologist and electrophysiologist are different specialties, says one coder. Sometimes she resubmits the electrophysiologist consults using a subsequent visit code.