Ophthalmology and Optometry Coding Alert

Question: I know Medicare doesn’t reimburse consults anymore, but a new coder we hired said that at her old practice, she continued to get paid for consults if the primary payer accepted them and Medicare was secondary. She said as the secondary payer, Medicare will pay consultations. Can you direct us to the regulations on this?

Arizona Subscriber

Answer:   It’s true that the primary payer — if it’s a non-Medicare insurer — may still reimburse you for consultations. However, even if Medicare is secondary, your MAC still won’t pay a dime for consults. “Medicare will no longer recognize the consultation codes for purposes of determining Medicare secondary payments (MSP),” CMS said in MLN Matters article MM6740, which 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. 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; 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 appropriate for the service, to Medicare for determination of whether a payment is due.

CMS indicates in the MLN Matters article that “the first option may be easier from a billing and claims processing perspective.”

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 covered by Medicare.

To read the MLN Matters article on MSP claims billed after Medicare’s 2010 consult elimination, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.