Wiki Billing Consult Codes to Primary Comm Insurance and Secondary to Medicare

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I have a patient referred to our office for a consult. Patient has commercial insurance as primary and Medicare as secondary. Would you still bill Medicare as a consult? Thank you. Tina C
 
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No, Medicare no longer accepts consultation codes. You may be able to bill a new patient office code that corresponds with the level of your consult code that you billed the primary insurance.
 
It does not work to change the code for submission to Medicare as the consult codes have no equivalent codes, Medicare will deny for not matching the EOB. Medicare put out an instruction early on that stated you either bill the primary as a consult and know that Medicare will deny and you will write it off or bill the primary the same as you would bill to Medicare.
 
This might depend on your Medicare carrier. Our Medicare carrier has told us that we can bill a consult code to the primary and then change the code to an equivalent code based on the documentation. As both consult codes and new patient codes have the same criteria (except obivously for documenting the request for consult for the consult codes), the change should be corresponding, 99243 and 99203 both require a detailed history, detailed exam and low complexity MDM. We have not had any problems billing with the change in code. Medicare has not denied any of the secondary claims. Check with your Medicare carrier. Also, check your reimbursements and what the patient copays are, if the patient has a $40 copay, it might make more sense to bill the new patient visit and be able to bill to Medicare to get the copay back rather than bill the consult and write off the balance. In contrast, if the patient has a $10 copay it might make more sense to bill the consult code and write the balance off rather than bill Medicare. Commercial insurances usually pay more for the consult code than the new patient codes.
 
We haven't had a problems changing the code either. The only other thing I would recommend is overriding the fee (if it is different) so that the charges are the same as the EOB. The only time I got a denial was when I forgot to do this, then it was denied because the EOB didn't match the charge.
 
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