Modifier Coding Alert

Question: We are in a large GI group all under the same tax ID. One of our physicians does procedures that none of the other GIs in our group are able to do. The scenario is: Another GI sees a patient in the hospital and decides that he needs one of these procedures that only one physician 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 Subscriber

Answer: Yes, your physician who will perform the procedure can get paid for both the consultation using 99251-99255 (New or established patient initial inpatient consultation services…) and the procedure. He will have to back up the claim with excellent documentation though. The billing will need to include 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.). If by a rare chance 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 won’t 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 GI can perform is considered 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 are very expensive. You may not be able to get paid enough in appeal to cover the cost of the consult. You need to consider your options to avoid losing money.