Wiki Initial Consult vs follow up

[dtamayo]

We are provider office who accepts patients under their auto insurance (personal injury protection) just for the initial visit. The provider has recommended injection for patient and we will be using her health insurance (BCBS). Do we see the patient as follow up with a possible injections or can we bill as an initial visit with a possible injection? We want to be in compliance but not sure how this can be billed. Any info would be appreciated.

 

[smoore123]

Good Morning,

This portion of your statement is not clear; " Do we see the patient as follow up with a possible injections or can we bill as an initial visit with a possible injection?" Are you looking for guidance on if you should bill the initial visit E/M and the injection on the same DOS or if you should have the patient come back in follow up and bill for a scheduled injection without an E/M? MV laws also differ from state to state so you may want to look into that as well.

 

[dtamayo]

Good Morning,

This portion of your statement is not clear; " Do we see the patient as follow up with a possible injections or can we bill as an initial visit with a possible injection?" Are you looking for guidance on if you should bill the initial visit E/M and the injection on the same DOS or if you should have the patient come back in follow up and bill for a scheduled injection without an E/M? MV laws also differ from state to state so you may want to look into that as well.

I am trying to find out since we have already billed the patient a new E/M visit under her PIP , now that she is coming in for a second time for injection that the provider recommended and this will be under her own personal health ins , do we have to see her as a follow up visit and injection or can we see her as a new patient under her health insurance with injections. I hope this was a little bit more clear. I appreciate any feedback.

 

[smoore123]

Please review the new vs. established patient guidelines in your manual. This patient would be considered established. However, it sounds like your are bringing the patient back for the injection which had already been decided at the prior visit. Unless the provider addresses something else that is significant and separately identifiable to support the billing of the E/M visit with a modifier 25 you should only be billing the procedure. I have attached a modifier 25 decision tree that you can use as an educational resource with your providers. Additionally for more information, refer to the “Medicare Claims Processing Manual”, Chapter 12, Section 40.2, at http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/downloads/clm104c12.pdf