Betsy Nicoletti, MS


June 24, 2019

The Coding Expert Answers Your Questions

Editor's Note:
Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti gives advice on billing a consult the right way and helps determine why a skin examination was denied payment.

Why Are My Consult Codes Getting Rejected?

Question: I am a maternal-fetal specialist, and often do a consult and an ultrasound for the initial visit. Currently, my consults are being rejected by payers. What is the right way to bill?

Answer: There are three issues with this question.

First, I assume you are not the physician who is providing the global maternity care package, doing all of the prenatal visits and delivering the baby, but instead are being asked by another ob-gyn to evaluate a pregnant patient. If you are in the same practice as the physician who is asking you to evaluate the patient, the payer may deny any evaluation and management (E/M) service incorrectly, considering it part of the maternity care global payment. In that case, you need to appeal the denial, with evidence of your subspecialty designation.

Second, an E/M service performed on the day of the ultrasound will require appending modifier 25 to the visit code. This indicates a significant, separately identifiable E/M service on the day of a procedure for which separate payment may be made.

Third, some commercial and managed Medicaid programs stopped recognizing consultation codes 99241-99245 and 99251-99255. Medicare stopped paying for those codes in 2010. Some other payers stopped at this same time, and others have stopped since then. If the services are being denied because the payer does not recognize consult codes, use a new or established patient visit code.

If you are in the same group with the ob-gyn who sent the patient to you, the visit will be an established patient visit. If the payer recognizes and pays the consult codes, be sure to document the request from the physician or midwife, and return a copy of the report to the requesting clinician.

Your staff may need to call the payer to determine the exact reason for the denial. Unfortunately, the reason a claim is denied is not always clear from the reason code on the explanation of benefits.

Coding for a Patient With a Skin Condition

Question: A primary care physician in our office saw a new patient concerned about a skin condition. She billed 99202 as the Current Procedural Terminology (CPT) code and Z12.83 for the diagnosis. The service was denied. Why wasn't it paid?


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