Wiki Interprofessional specialty codes, Billing sequence for 99204,99451 & 99446

[Christinap@medi.ci]

We are a internal medicine/ Family medicine practice that uses an outside on call specialty group to consult with for patient concerns that could not be addressed by a PCP. WE are anticipating billing a new patient visit for this newer patient population such as a 99204 and I assumed we would be that on the same DOS as the 99451 with a 25 modifier. If Im correct we would then bill the 99446 when we received feedback from the specialist alone on a separate encounter/superbill. Once we scheduled the patient for a follow up we would then only bill the 99213 etc after alone. I've never dealt with these codes before and i'm trying to ensure this is a seamless process for our providers. What do you think ?

 

[Pam Warren]

I think you should read the section in CPT regarding these codes. As the consultant, you cannot bill that interprofessional consultation when there's an E&M visit within the past 14 days or the next 14 days. I'm not sure how your outside specialty group plays into this scenario, and if they are acting as covering providers, essentially they are the same group. These consultations are billed only when a requesting provider (PCP, hospitalist, etc.) contacts the specialist in order to get consultative advice on behalf of the patient, after which a report is written. The specialist who renders the advice is able to bill. What is the medical necessity of your group seeing the patient as well? I'm not sure I understand what you're intending to bill, but it doesn't sound like you quite understand the intent of the code (or maybe I'm reading this wrong).

 

[Christinap@medi.ci]

Here is the scenario.
A patient see's our PCP for a problem (a rash for example) Our doctor a PCP says i'd like to consult an on call same day specialist to see if they can provide feedback on this rash. I then bill the 99204, 99451 w/ a 25 modifier. The patient was a new patient to our practice and then we submitted to the inter-professional specialist.

The on-call specialist reads the report and responds back the next day. I would bill the 99446 for inter-professional feedback, then a 99213 etc for the follow up on a different DOS.

I have not read anyway that we cannot bill an office visit within a 14 day period. I do know that you can only bill those two inter- Professional codes once within a 7 day period.
It is possible you are completely right, We have never billed these two codes but are offering same day specialist services. These on call specialists do not work within our practice we have a seperate contract for their services and they will not be billing the commercial ins for these codes.

 

[Pam Warren]

If your patient is new to the practice/provider, then you can bill the new patient E&M visit. 99451 is billable only by the consultant, not the referring provider. So the 14 day guidance won't apply to your providers, but neither do these interprofessional codes....as the PCP, these aren't billable by you. The 99452 is the only code you may be able to bill, but it's tough because of the time required to bill it. This code is for the preparation for the actual referral to the consultant, and they would have to provide more than 16 minutes of time getting that referral in place. No doc spends that kind of time, and it would have to be separate from the E&M that you've already billed. Our docs don't bill it because they don't meet the time requirements. Ever. 99446 is for the Consultant's feedback to the PCP...not for the PCP to bill.
So because you don't bill for the consultants, none of these codes (except 99452) will ever apply to you. NAMAS and CodingIntel (Betsy Nicoletti) both have nice articles on these codes, with explanations as to their use. The CPT book is pretty clear also. If the consultants are not billing these services, they are losing out, but these are not PCP codes.

Also, I don't see mention that you obtained consent from the patient. As the referring provider you are obligated to do this.

 

[Christinap@medi.ci]

Yes we have consent in place in order to communicate the patient's needs to an outside specialist. I appreciate the information on the 99451 CPT as we were told by the commercial and via our contract that these code would be acceptable to bill and were reimbursable. We are just learning this process and are new to billing fee for service. We pay the outside on call specialist for their consulting time they are not billing for it. It may be a trial and error, as i'm a bit confused on why the 99452 would be hard to prove time spent. They need to review the specialists feedback and relay that information back to the patient. So in our best case scenario we bill NP E&M, 99452 and then f/u visit. Please feel free to weigh in.

 

[Pam Warren]

99452 is not for reviewing the feedback.....it's for the initial referral work. Do not bundle the E&M with the 99252 unless you don't include any of the referral work in the calculation of the E&M; you have to bill separately identifiable services in order to append the -25.

If you're new at billing and fee for service, you may want to get some more information on how to compliantly report CPT codes. Do you have the most recent CPT books? Read the instructional notes carefully; this comes directly from the AMA. In this instance, you're being told incorrectly.

From CPT:
99451
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time
99452
Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes