Wiki E/M Consult, Initial Hospital, Initial Observation denials and modifier 25

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Retrophaze

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I work for a company that has on call surgeons. These surgeons get called into the ED to consult for patients who may need surgery. Of course, some are minor surgeries with 0- 10 day global and others are 90 day global. I know that Consults etc are done in the ED department and billed out. Our surgeons also do their own consult because we are a different "specialty". When we code a consult, Initial Hospital (MCR forces the use of these in place of consult codes), or Initial Observation, our claim is denied as "service already billed for and paid" however, we are not the ones who were paid (could be ED, or another specialist that was called). They tell us we must use subsequent codes. We were pondering the use of a modifier 25 when we bill our initial consults etc. due to us being a different entity. Modifier 25 is a muddy code in my opinion. I get the physician office use of it and the whole separate E/M code in those situations. But when the ED or another specialty (cardio etc) has also billed a consult, and we have actually done our own surgery consult, would a modifier play an important role in our coding/billing?

We also get a ton of 10 day globals in which we have performed a consult the DAY BEFORE the surgery, that are getting denied as well - insurance companies are telling us to use modifier 25 to get it paid. That just doesn't seem right to me since the global doesn't start until the day of surgery. And frankly, our E/M was all about the issue the patient has that requires surgery.

If anyone has anything educational they can point me to that would be great.

I appreciate any help I can get!
 
Consult in the ED

If the ED provider or other provider in the ED asks for a Consult in the ED and the patient is not an IP at the time , use the ED codes. POS 23. That second provider requesting your opinion might be billing the Admission, but not you.
Tricia D
 
Thank you Tricia! Sometimes we do use ED/emergency codes, but for the most part our patients are getting admitted by the time we see them and we are at a POS of 21 (I know, ours is unique). When I pull up the definition and use of mod 25 in Chapter 12 part 40 and 40.1 in Medicare, I am interpreting it as such that our part in the process should not need that modifier. I am not a coder who throws modifiers on just to get things paid. If an insurance company instructs me and I can't win the discussion, I document it and proceed. But not because I want to. However, in order to update our insurance company guidelines, I am trying to come up with some other proof that we do not append this but we do need to appeal the denials using that section of the Medicare guidelines. I know my situation is not and average scenario.
 
dtricia said:
If the ED provider or other provider in the ED asks for a Consult in the ED and the patient is not an IP at the time , use the ED codes. POS 23. That second provider requesting your opinion might be billing the Admission, but not you.
Tricia D
Click to expand...

The use of ED consult codes 9928x and POS 23 should be used only when the patient is seen in the ER and sent home, without admission to OBS or IP.
 
Hospital consults during post-op

One of our physicians performed a tonsillectomy on a patient. Several days later our other physician was on call and had to see her at the hospital (POS 22) for a potential bleed. This physician determined nothing should be done so we planned on billing a simple E/M but aren't sure how exactly to code this.

We don't believe we should use modifier 24 because it was related to the original surgery. We also don't think 25 because it wasn't the same date of service as the surgery. And 78 or 79 doesn't quite fit either because our physician did not perform a procedure.

Also, not sure if we should bill a usual consult code 9924X series or the 9928X series CPT. Any help is very appreciated.
 
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