Medicare Compliance & Reimbursement

Question: An established patient who was about to undergo a tonsillectomy presented to our office for a pre-operative clearance exam. Which code should we report to her Medicaid insurer for this visit? Answer: Ideally, you should report a consult code from the 99241- 99245 series for the visit. However, starting in 2010, Medicare discontinued recognition of the consult codes, which pay 40 percent more than other E/M codes that have comparable levels of history, physical exam and medical decision-making. If your Medicaid provider is following this policy, then use an E/M code (99201- 99215) for the visit and the appropriate V code for the preoperative exam (V72.81-V72.85). Listing the reason for the surgery as the primary code (and the V code as the secondary code) can be helpful with some payers. For instance, if your Medicaid program is not recognizing consultation codes, you might report 99213 for the visit, linked [...]