Wiki Office visit vs consult

[ca_cpc]

I work at a primary care office, but we have a neurologist starting. There's been discussion on billing office visits (9920-/9921-) vs consults (9924-). Apparently BCBS is the only one of our carriers who will cover consult codes, so the current plan is to bill consults to BCBS but office visits to everyone else. I understand the logic here, but it makes me uncomfortable to bill different codes for the same service based on which carrier will cover them. My instinct is that if they can be considered office visits, we should be billing them as office visits to ALL carriers. That said, I've never dealt with specialists and consults before, so I don't actually know if this could be considered more along the lines of the carriers WANTING a different code for the service. Thoughts?

 

[Chelle-Lynn]

When Medicare stopped allowing for the consult codes this caused a lot of confusion and questions due mostly to various carriers such as BCBS still allowing for these services. The answer to your question comes down to what the carrier allows for and what the documentation supports.

For BCBS if the documentation supports the coding of a consult service and the carrier in question allows for consults, then it is appropriate to bill for the consult. If the carrier in question does not allow for the consult then it is appropriate to level the claim as a regular E&M. From a coding and compliance view point you are correct to code the claim as most appropriate based on the services rendered and the individual carriers policy. In this case Medicare instructs us to level the claim based on the standard E&M codes so we within the guidelines to do so.

I have provided the link for the a good AAPC blog on this issue.

https://www.aapc.com/blog/26168-consult-your-payer-for-consult-guide-lines/