Wiki Consult in ER by Hospitalist

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jdibble

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Our hospitalist was called to the ER to consult on a pediatric patient with a sore throat. The hospitalist did the consult and recommended that the patient be given antibiotics and be sent home. The hospitalist billed 99242. Now BCBS is denying claim stating that the procedure is inconsistent with the place of service and suggested billing the correct POS. They are denying this saying the 99242 is not payable in the ER.

Can someone offer what code we should be billing with? According to CPT this is the correct code for a consult in the ER, so I am not sure what they want. The ER doc billed the codes for the ER and since this is not a medicare patient, I know we can't bill that code too!

If anyone has any ideas of what code we should be billing - or if we coded this right, I would appreciate your response!

Thanks,
 
consult in ER by Hospitalist:
Jodi, it really fits as you places as per the Coding manual. But do the careers view differently the ER service in Hospital setting than an ED in facility Service so much so to weigh on the POS rather than the type of service requested, as we all know that the consult for ED is to be placed from Office /outpatient consultation as per guidelines.
Consult is a consult (as perthe definition in our manual) be it required of a Hospitalist or Specialist Consultant.
Or, are the payers trying to remove or avoid the consulation E/M code in this scenario?
May be they do not take the hospitalist consult as a "consult" ( if not a Ped hospitalist?)
May be they just consider as the attending physician??!!
By coding rule and in the coding world, it is not correct to turn the table to 23 instead of 22.
But in realty, the ER of a hospital does not belong to the office visit or outpatient consultation. In that way, ER- E.D is the POS.
I think you should get an explanation from them as to why should it be from ER E/M code as a deviation from the general norms of our coding guidelines?
 
consult done in Er

I assume that the provider saw the patient in the ER. Why couldn't you just use the E&M codes for the ER, especially if the POS is for he ER? Any physician can use the ER codes if the pt. was seen in the ER.
 
I have noticed that some bc/bs claims are being subjected to the no consult code law
used by Medicare. It might be that you need to use a new office visit code for the consultation. Also If you did bill the consult be sure that you used the correct pos ER and not as inpatient. You might just have to appeal and explain the rule to them as sometimes
the insurance companies deny without really looking at the situation.
 
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