Ophthalmology and Optometry Coding Alert

Don't even think about billing a consult to Medicare -- even if the claim is to a Medicare secondary payer.

Medicare may have scratched consultations off its list of payable services, but many other insurers did not follow suit. The dual system leaves you in a quandary when your physician performs a consult and the primary non-Medicare insurer pays you for the service, but Medicare is the secondary payer.

The "Medicare Secondary Payer (MSP) will not pay for consults," says Samantha Daily, billing specialist with a practice in Portland, Ore. 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 using an E/M code, and then report the amount actually paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or

• 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 equal to the service, to the MSP for determination of whether you are owed additional payment.

"The first option may be easier from a billing and claims processing perspective," indicates CMS in the MLN Matters article. "There's essentially no workaround to 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 in West Chester, Penn.

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 and determines code assignment. 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. "Medicare has created a genuine mess, and unfortunately there are providers who now have simply informed their staff that the physician will no longer accept consult requests for Medicare patients, and if a consult is requested for a Medicare patient, they're 'not available,'" Burleigh says.

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