Radiology Coding Alert

Medicare may have sent consult codes to the chopping block, but some private payers have kept those codes on their payable list. Result: You have to decide what to do when the patient's primary insurer is willing to accept a consult code, but Medicare, as the secondary payer, will not.

Early on, when the transition from using consult codes was first being discussed, one of the issues still up in the air for coders was what to do if Medicare is the secondary payer, says Sandy Fuller CPC, MCS-P, HIS supervisor and compliance officer for Cardiovascular Associates of East Texas.

Outcome: 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:

1. 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.

2. 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.

"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.

And you may want to weigh the time staff requires for each method against the amount of reimbursement expected.

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 turns out to be on Medicare.

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