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Secondary Payor Doesn’t Recognize Consultations
We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?
Question:
We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?
Answer:
We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.
*This response is based on the best information available as of 02/16/23.
Repair of Nasal Valve Collapse
I perform repairs of nasal valve collapse with radiofrequency and have been using an unlisted code. One of my colleagues told me there is a new code for this procedure in 2023. Can you provide the code I need to use?
Question:
I perform repairs of nasal valve collapse with radiofrequency and have been using an unlisted code. One of my colleagues told me there is a new code for this procedure in 2023. Can you provide the code I need to use?
Answer:
In 2023 a new code was added. CPT 30469 is the correct code to report a nasal valve collapse with low energy temperature controlled subcutaneous/submucosal remodeling which includes radiofrequency.
*This response is based on the best information available as of 02/02/23.
Forehead Flap
Our Otolaryngologist routinely does repairs after Mohs surgery. What CPT code do I report for a paramedian forehead flap to reconstruct a nasal defect after Mohs surgery.
Question:
Our Otolaryngologist routinely does repairs after Mohs surgery. What CPT code do I report for a paramedian forehead flap to reconstruct a nasal defect after Mohs surgery.
Answer:
The correct code to report is CPT code 15731 (Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap).
*This response is based on the best information available as of 01/19/23.
Consultation Coding in 2023
In 2023, will the level of service be determined by history, exam and medical decision making, or will this change? I have heard it is changing.
Question:
In 2023, will the level of service be determined by history, exam and medical decision making, or will this change? I have heard it is changing.
Answer:
Beginning January 1, 2023, consultation codes 99242-99255) for both inpatient and outpatient services will be based on medical decision making or time. However, keep in mind a clinically relevant history and clinical examination should also be documented. Also, consultation codes 99241 and 99251 have been deleted.
*This response is based on the best information available as of 12/15/22.
Oral Food Challenge
What needs to be documented to support billing CPT code 95076/95079?
Question:
What needs to be documented to support billing CPT code 95076/95079?
Answer:
Complete documentation is critical for oral challenges. Be sure to document:
- Time testing begins and ends
- The amount of food or drug given
- Any adverse reactions
- Discussion of test results
*This response is based on the best information available as of 12/01/22.
Billing an E/M Service on the Same Day as an Oral Food Challenge
My physician always bills an E/M service with CPT codes 95076/95079. Is this allowed?
Question:
My physician always bills an E/M service with CPT codes 95076/95079. Is this allowed?
Answer:
It’s rare to bill an E/M code with an oral challenge unless the provider needs to treat for a reaction (intervention therapy – a separate service) or the provider saw the patient for an unrelated office visit the same day as testing.
The office visit cannot be part of the testing and needs to significantly separately identifiable. You cannot double-count the testing time for both the oral challenge and the E/M code! If you do code an E/M visit with an oral challenge, add modifier 25 to the E/M code (99202 – 99215).
*This response is based on the best information available as of 11/17/22.