Wiki 99452-Advice

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kanoepascual

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I was hoping to get some guidance on CPT 99452 if possible? Reading AAPC article: https://www.aapc.com/codes/coding-n...icesthat99451and99452represent-159856-article states: "99452 represents when a provider (such as the patient’s primary care physician or other qualified health care professional) interacts with a consulting provider via telephone, the internet, or an EHR. The communication is initiated so the primary provider can share information with the consultant to help him or her form an opinion about the patient’s future treatment or care management."

I have a PCP that will see a patient & later that day will consult a specialist regarding patient's plan of care. Per NCCI edits you are not allowed to bill a E/M service along w/a 99452 & I'm not able to override it with a modifier 25. I do understand why a consultant cannot bill for 99446-99449 & 99451 if they see a patient within 14 days; but for a 99452 all it states is that this cannot be reported more than once in a 14-day period. Any advice on how to bill the 99452 with an E/M would be greatly appreciated! thank you!
 
Where do you see an edit for an E/M with this CPT? I don't see any. Some payers may decide a 25 is needed but NCCI edits don't show this. Is it possible your specific billing system has an edit in place when trying to enter these?
There is a CPT Assistant about these codes: June 2019/Volume 29 Issue 6.

I am no expert in these codes but if the intent of these is for complicated situations or urgent need to consult, it makes sense that it would be done on the same day. I think the issue might be same day reporting for some payers. It seems you would have to show that the patient was not on-site and with the physician/QHP at the time of the consultation. You may have to check each individual payer rule for this.

"UnitedHealthcare aligns with CMS and considers interprofessional consultation codes 99451-99452, 99446-99449 for reimbursement. For the above consultation codes to be considered for reimbursement, the following documentation requirements must be met: • A written or verbal request for consult must be made by an appropriate source • The request must be documented in the patient’s medical record • The consultant’s opinion must be documented in the patient’s medical record • The consultant’s opinion must be communicated by written report to the requesting physician or other appropriate source The requesting physician or other appropriate source must be identified on the claim. If the requesting entity is not identified on the claim, the consultation service will be denied because it does not meet requirements for reporting such a code."

"Keep in mind, these codes are not used for non-face-to-face telephone or online consultations with patients, parents, or guardians; those are reported via codes 99441–99444. Coverage for codes 99441–99444 varies by payer and, by definition, includes restrictions when the communication originates following a face-to-face visit and/or leads to a face-to-face visit.
 
Thank you for your response and links!

According to CMS NCCI edits you are unable to bill for both services. What's difficult is any information that I'm reviewing allows me to bill both an E/M as well as a 99452 for our treating physician.
CPT only copyright 2021 American Medical Association. All rights reserved.
993509945220201001*0CPT Manual or CMS manual coding instructions
993509945220190101201912310CPT Manual or CMS manual coding instructions

Also this is the edit I get when using the Codify claim scrubber:
Procedure/Supply:
    • NCCI edit: This procedure code can never be reported together with code 99350 due to NCCI column 2 code edit
If anyone is utilizing the 99452 for their treating PCPs I would greatly appreciate any advice on how you guys are billing these out? I understand why a consulting physician cannot bill for a 99446-99451 if they see the patient within a 14-day face-to-face visit; however there's very little guidance on how to apply the 99452 from valid sources.

Here's some of the info I've been reading, but would love to get any other links from CMS/MLN/Noridian JE/Ahima, etc:
https://www.cchpca.org/2022/03/2022BillingGuidefinal.pdf
https://practice.asco.org/sites/def...12/Final-Rule-2019-Resource-FINAL-12-5-18.pdf

Usual scenario is: 1) Provider sees patient at home via telehealth or face-to-face, 2) Needs advice from a specialist; therefore she'll reach out via phone or video visit at end of day, 3) With advice from specialist, provider will plan future care of patient. Due to most patients being homebound, she does not refer her patients out to a specialist.

Just need some help or guidance on this...thank you so much again!
 
kanoepascual said:
Thank you for your response and links!

According to CMS NCCI edits you are unable to bill for both services. What's difficult is any information that I'm reviewing allows me to bill both an E/M as well as a 99452 for our treating physician.
CPT only copyright 2021 American Medical Association. All rights reserved.
993509945220201001*0CPT Manual or CMS manual coding instructions
993509945220190101201912310CPT Manual or CMS manual coding instructions

Also this is the edit I get when using the Codify claim scrubber:
Procedure/Supply:
    • NCCI edit: This procedure code can never be reported together with code 99350 due to NCCI column 2 code edit
If anyone is utilizing the 99452 for their treating PCPs I would greatly appreciate any advice on how you guys are billing these out? I understand why a consulting physician cannot bill for a 99446-99451 if they see the patient within a 14-day face-to-face visit; however there's very little guidance on how to apply the 99452 from valid sources.

Here's some of the info I've been reading, but would love to get any other links from CMS/MLN/Noridian JE/Ahima, etc:
https://www.cchpca.org/2022/03/2022BillingGuidefinal.pdf
https://practice.asco.org/sites/def...12/Final-Rule-2019-Resource-FINAL-12-5-18.pdf

Usual scenario is: 1) Provider sees patient at home via telehealth or face-to-face, 2) Needs advice from a specialist; therefore she'll reach out via phone or video visit at end of day, 3) With advice from specialist, provider will plan future care of patient. Due to most patients being homebound, she does not refer her patients out to a specialist.

Just need some help or guidance on this...thank you so much again!
Click to expand...
Ah, I see I was thinking when you said E/M you were referring to office/outpatient 992_ _. Helps to know the specific code or code range in question and not just "E/M". :)
If it has the indicator 0, you can't code them together, period. "Codes are always bundled; do not submit a modifier for exceptions."

My first thought was a G code or 99417. There are a lot of time and other requirements if reporting 99417. Not sure if this would work for you or not.
CPT says list separately with 99350 as one of the parent codes.
 
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