Ob-Gyn Coding Alert

If you have payers who didn't play follow-the-leader with Medicare in cutting out consult codes, you have a dilemma on your hands. You have to decide what to do when your ob-gyn performs a consult, the primary insurer pays you for the service, and Medicare is the secondary payer.

CMS announced the "Medicare Secondary Payer (MSP) will not pay for consults," says Samantha Daily, billing specialist with a practice in Portland, Ore.

Recently published MLN Matters article MM6740 indicates the following: "In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation ...]. If the primary payer for the service continues to recognize consultation codes," you should bill in one of the following two ways:

• Bill the primary payer an E/M code, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due.
• Bill the primary payer using a consult code, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

"The first option may be easier from a billing and claims processing perspective," indicates CMS in the MLN Matters article.

Example: A family physician sends a 70-year-old patient to the ob-gyn because of increased complaints of  urinary distress. The family practice physician asks for a consultation regarding treatment options for his patients. The ob-gyn performs a consultative service and performs both a comprehensive history and examination on the patient (who is new to the practice). The ob-gyn documents moderate medical decision making. He sends back a report of his findings to the family practice physician.

Option 1: The ob-gyn understands that the patient has Medicare as secondary insurance. Instead of billing the primary insurer code 99244 for this service, he bills 99204 (Office or other outpatient service for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity...).

Option 2: Assume this is same patient. In this instance, the ob-gyn submits 99244 to the primary insurer. This payer reimburses for the service. The code that you send to Medicare, however, must not be 99244 but 99204 with the amount paid for 99244.

"There is essentially no workaround for this situation, so you have to decide whether you will get paid better via payment from the primary insurer with a consult code versus the alternative (billing an E/M to both payers)," says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Consulting located in West Chester, Pa.

Potential snag: In some cases, such as a physician seeing a hospital patient, the doctor may not know whether the patient is on Medicare or has a different insurer when he documents his consultation. Coders will need to be able to glean an appropriate E/M code from the physician's consult documentation if the patient ends up being on Medicare.

To read the MLN Matters article on the consult elimination, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.