Wiki Can 99222 be billed twice on the same DOS?

[anom]

DOS is 1/12/23.
A psychiatrist billed 99222 for the consult he had in collaboration with an APP..
Three hours later a neurologist consulted in collaboration with her APP and also billed 99222. The neurology consult was denied. Should I just rebill it and append modifier -25 to it?

Please advise.

 

[csperoni]

Clinicians of different specialties can both bill for their services.
You do not specify why it was denied, but I will make an assumption based on my past experiences. SOME insurance companies will not pay more than 1 clinician for the "initial" hospital visit. Their guidance is for the admitting to bill the initial and all other clinicians to bill as subsequent. This is not the Medicare guidance, which specifies multiple clinicians may bill initial and the admitting bills with -AI modifier. If the carrier has a policy to only pay 1 clinician for initial, -25 will not override that. If this is their policy, then you must convert to subsequent.

 

[anom]

Clinicians of different specialties can both bill for their services.
You do not specify why it was denied, but I will make an assumption based on my past experiences. SOME insurance companies will not pay more than 1 clinician for the "initial" hospital visit. Their guidance is for the admitting to bill the initial and all other clinicians to bill as subsequent. This is not the Medicare guidance, which specifies multiple clinicians may bill initial and the admitting bills with -AI modifier. If the carrier has a policy to only pay 1 clinician for initial, -25 will not override that. If this is their policy, then you must convert to subsequent.

Denial reason stated that only 1 initial hospital visit can be billed per admission. The payer is Amerigroup. When I asked another coder, I was advised to just append modifier -25. I'm sure that is not accurate in this case. I'm a new coder who has been tasked with working coding related denials. I was given about 10 minutes of training on how to work /respond to these type of denials and I do not have access to payer policies/guidelines or websites. I was told I didn't need them which is odd. When the denial is related to coding, the denial team transfers the account to my work queue. I'm a little frustrated but I'm still learning with limited resources. Any help is appreciated.

 

[amyjph]

Like Christine said, it's payer dependent and you would have to drop to subsequent if the payer says no.
Was just discussing on another thread: https://www.aapc.com/discuss/thread...t-consultations.191388/?view=date#post-524612

I don't see how you can work a denial list without access to payer policies and guidelines... seems off to me. That would be like saying you can't use code books... Unless you have access to an Encoder program or some other internal resource that has it built in.

 

[anom]

Like Christine said, it's payer dependent and you would have to drop to subsequent if the payer says no.
Was just discussing on another thread: https://www.aapc.com/discuss/thread...t-consultations.191388/?view=date#post-524612

I don't see how you can work a denial list without access to payer policies and guidelines... seems off to me. That would be like saying you can't use code books... Unless you have access to an Encoder program or some other internal resource that has it built in.

Thank you both for chiming in. Prior to becoming a coder, I used to work on prior auths at another company. I had access to provider portals and knew payer guidelines that were specific to the speciality but I'm on the other side of fence now and am a little lost. I was given access to an Encoder but no training on how to used it. I'm googling and youtubing as we speak. I want to fully grasp what I'm doing and ensure that I'm doing things the accurately and efficiently, especially if I'm the last person to touch the account.

 

[TThivierge]

Hi Anom
You will learn with payer denials but it can be frustrating. Here are some tips. ...use the CPT and ICD10 manual for Excludes rules, Code first vs Additional Codes, first list Z codes , use of modifiers, unbundling CPTs, plus areas of the body to understanding the procedures & dx in conjunction with their documentation and setting. Goggle the payer rules, print out and put in manual for referencing and keep account of which med service has most denials on common treatment issues. Later need to inform the providers & med coders. Payer will denied if not received medical record when modifier 22 or 52 used, ensure use laterality codes of RT or LT for organs with 2 sides, add referral physician when needed on claims, if preapproved for certain dx code, hopefully providers use same dx code listed on preauthorized insurance paperwork, Etc. Learn inpatient coding rules......create cheat sheet or handout of notes or websites such as NCCI to refer to aid you.
Good Luck
Lady T

 

[anom]

Hi Anom
You will learn with payer denials but it can be frustrating. Here are some tips. ...use the CPT and ICD10 manual for Excludes rules, Code first vs Additional Codes, first list Z codes , use of modifiers, unbundling CPTs, plus areas of the body to understanding the procedures & dx in conjunction with their documentation and setting. Goggle the payer rules, print out and put in manual for referencing and keep account of which med service has most denials on common treatment issues. Later need to inform the providers & med coders. Payer will denied if not received medical record when modifier 22 or 52 used, ensure use laterality codes of RT or LT for organs with 2 sides, add referral physician when needed on claims, if preapproved for certain dx code, hopefully providers use same dx code listed on preauthorized insurance paperwork, Etc. Learn inpatient coding rules......create cheat sheet or handout of notes or websites such as NCCI to refer to aid you.
Good Luck
Lady T

I'm on it! Thank you!! I've been keeping record of the denial reasons per payer, Px and Dx to track trends and for my own point of reference. Most of the denials I'm seeing are related to est patients being billed as new patients or Dx not being billable or sequenced properly. It would help me a great deal to know the payer guidelines so I can remedy the denials more effectively. Since I've been tasked with other responsibilities, in addition to the denials, I was told I didn't need that information but I know better than that Lol. I'll learn on my own and find the right points of contact to guide me as I continue to develop. I wish I had a seasoned coder to mentor me because things can get frustrating when you don't have a team of other coders to work alongside with, leadership is just as inexperienced as I am when it comes to coding and I have 2 colleagues who offer support but they have their own full workload and I'm at the mercy of their availability. But, it'll get better for me. I'm determined to learn. I appreciate you and everyone who chimed in. Thank you all!!

 

[TThivierge]

Hi Anom
Good for you!! This save info will help you in the future in managing denials. I code a variety of outpt clinics....I ll list some denials I run into. Even though I code daily the billing department sends back the denials to view. Of course denials can be govern by differ payer rules but here are some basic ones may help you in the future. Later make sure you show your boss how you have worked on solution ...your research in lessening insurance denials and share the data.
Consultations CPT 99243- ensure list referring doc on claim plus definitive dx . Also Medicare DOES NOT accept consult codes. If pt is inpt status use subsequent inpt. CPT code. Also the referral provider should send a report later.
Dx Sequencing- the ICD10 manual guides you but off hand if pt has gotten infection and it is listed lab results add it. See dx B95-B97 = dx N39 UTI or Respiratory Ds J98 J01, J10 Etc, Gastritis or any stomach problem dx K57 or K25 with positive lab results A04-A05
Also ensure add Chronic Pain G89 if pt has limb in which doctor states chronic pain,.Add it after the limbs or body parts with pain see dx hurting M54, M25 vs M79 .
Understand there are dx code define certain stages or types of certain areas of the body. The provider 's note should be detailed and specific. Some use a unspecific dx code ending in .9 or ,09. Here are some level of codes per location to be aware of Colon Polyp vs Neoplasm see dx D12& K63 ,D37, Colon has 4 areas too. Types of Hernia per location dx K40-K43 Hemorrhoids K64, Injuries, Fractures, Hypertension, Arthritis,Heart Dx, CHKD dx N18-1-N18.5 and DM E11 has complications of eye, skin problems just to name a few.
You will get a denial if not list how injury occurred and where it occurred plus Date of Injury (DOI) on the claim. Mostly ERM, doc visits, and Xray visits want this data
If female patient has physical or annual pap use CPT G0101 Q0019 Q0011 and per age and if est. or new pt,(99396 CPT) plus dx reason plus Z01.4 or Z12.4. Also if she has a menstrual period the claim will want her LMP last monthly period on claim or deny it. There is a field on CMS 1500 claim.Preg test use correct dx Z32.
Most EMR system will put the most expensive treatment first on the claim, ensure use modifiers where needed 25, 50, 51, 59=XS
Ear ringing then clean out ears, use CPT 69210, add LT or RT or can do modifier 50 link with dx block H93 per which ear -check CPT manual
Also whatever problem the doctor or provider discuss first due to reason seek treatment. This should be put first as dx list. Providers know to do this ..list dx in order of importance.
Injections see CPT 96372 with J code & amount. Then see CPT 90471 uses dx Z23 and list J codes define medications & list correct amounts injected.chemo therp put dx Z51 first and J code & infusion CPT 96413 . Oh yes Phy Therapy..need add referring doc, and modifier GO, GN or GP per type of clinical staff or provider to claim in line with care.
Combo Dx codes... the dx E66 Obesity if list BMI in the medical record for the day treated then see dx Z68
Well hope these coding tidbits help in doing insurance denials
Lady T

 

[amyjph]

I'm on it! Thank you!! I've been keeping record of the denial reasons per payer, Px and Dx to track trends and for my own point of reference. Most of the denials I'm seeing are related to est patients being billed as new patients or Dx not being billable or sequenced properly. It would help me a great deal to know the payer guidelines so I can remedy the denials more effectively. Since I've been tasked with other responsibilities, in addition to the denials, I was told I didn't need that information but I know better than that Lol. I'll learn on my own and find the right points of contact to guide me as I continue to develop. I wish I had a seasoned coder to mentor me because things can get frustrating when you don't have a team of other coders to work alongside with, leadership is just as inexperienced as I am when it comes to coding and I have 2 colleagues who offer support but they have their own full workload and I'm at the mercy of their availability. But, it'll get better for me. I'm determined to learn. I appreciate you and everyone who chimed in. Thank you all!!

If I may ask, what type of practice or place are you employed? You shouldn't have to manually keep track of this information. The clearinghouse, EHR or software should have reporting capabilities to show these trends and denial/rejection data. Most have a dashboard type feature or put each type into "buckets" to be worked. Is it just that you are new and still learning your place of employment and workflow, or do they really not have this information and you are flying blind? (Scary) What is the volume of claims you are talking about? There is absolutely no way you will be effective/successful if you don't have access to payer guidelines and rules. If you have a high volume of new/established denials and diagnosis errors, that means your providers and coding team need education.

 

[anom]

If I may ask, what type of practice or place are you employed? You shouldn't have to manually keep track of this information. The clearinghouse, EHR or software should have reporting capabilities to show these trends and denial/rejection data. Most have a dashboard type feature or put each type into "buckets" to be worked. Is it just that you are new and still learning your place of employment and workflow, or do they really not have this information and you are flying blind? (Scary) What is the volume of claims you are talking about? There is absolutely no way you will be effective/successful if you don't have access to payer guidelines and rules. If you have a high volume of new/established denials and diagnosis errors, that means your providers and coding team need education.

I'd be more than happy to share that information with you privately for a number of reasons.