Wiki UHC denials on Inpatient Consultations

[lmcreynolds@aoamail.net]

Hello.

Has anyone noticed an increase in United Healthcare denials when billing 99221 or 99222? I work for an Orthopedic group. When we are on call, we receive many hospital physicians requesting us to consult on patients who have been admitted. Depending on the level of service, we bill 99221, 99222 or 99223 for our ortho physicians' consultations for patients with Medicare or Medicare products.

While reviewing the guidelines for Inpatient Consultations, we found "only one consultation may be reported by a consultant per admission". Does that mean "only 1 physician can bill a 9922- series codes" for that admission? Or does it mean "only one consultation per specialty"? If one per specialty, we are thinking that the admitting physician is not reporting their consult with the AI modifier.

Any help or insight on this matter would be greatly appreciated. Thank you.

 

[amyjph]

Could be an edit issue with claims processing due to the new 2023 updates.
Could be they are looking for subsequent codes for all other providers that are not the admitting on record.
Could be the admitting did not append AI.
What do the denials say? You "should" be able to use either initial or subsequent depending on the documentation. However, they may have a different idea...
Which guidelines are you referring to for IP consults? The quote you have above means only one consult per consultant. So, Dr. Ortho, Dr. General Surg, Dr. Vascular could all potentially report it. If you read the E/M section guidelines and intro in the book there are some other rules regarding site of service and when to report which code.

https://www.aaos.org/aaosnow/2022/dec/managing/managing01/

CMS Manual: 30.6.10 - Consultation Services
In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

Prior to the changes, when I worked ortho, it used to be much easier to meet the level and report the subsequent 9923_ so we normally did not report the initial unless we admitted which wasn't common.

 

[Sandyb11]

We are having this issue also, we are billing a 99221-99223 for consultations, we have always used these codes, now we can use them for outpt as well as for inpt. HOWEVER, we are getting denials from some insurance companies stating that the code has already been used/only one can be used per admission, so we are having to bill a subsequent visit. Medicare is not our problem, mainly United Health. This is not fair to the provider. I am open to any suggestions/help. 99244 etc. is not for observation so we do not have any other code to use that I am aware of.

 

[lgardner]

I found this UnitedHealthcare Policy, which states (emphasis added by me):
Dates of Service Beginning 10/1/2019 Consultation Services for all Providers: Effective for claims with dates of service on or after Oct. 1, 2019, UnitedHealthcare aligns with CMS and does not reimburse consultation service codes 99242-99245, 99252-99255, including when reported with telehealth modifiers for any practice or care provider, regardless of the fee schedule or payment methodology applied. The codes eligible for reimbursement are those that identify the appropriate Evaluation and Management (E/M) code which describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care service provided to the patient.