Secondary Payor Doesn’t Recognize Consultations

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.

New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is that the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.

Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three -year period.

In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

Changing Group Practices
What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:
The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in the Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period instead, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

E/M Visit During the Global Period

Question:

Can I bill an office visit in the global period if the diagnosis is different from why I did the original procedure?

Answer:

Yes, as long as the diagnosis is not for a related issue (e.g., complication from the original procedure). The documentation must be clear that the condition is unrelated to the original procedure and reflect a clear plan of treatment for the new/unrelated issue. You will then append modifier 24 (unrelated E/M in a global period) to the E/M code.

2021 Evaluation and Management Codes: Is a History Required?

Question:

My coder just told me about the new guidelines for 2021 office visit codes. She said I no longer have to document a History. This doesn’t seem right to me.

Answer:

You are wise to ask because that’s not exactly true. It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that you will document a “medically appropriate” (per CPT™ history for each encounter.

Modifiers on Unlisted Codes. Yes or No?

Question:

Can I use modifiers on an unlisted code? What about global period modifiers such as 58, 78 or 79? It seems reasonable to append those modifiers to the unlisted code.

Answer:

There is not a single right answer to this question. CPT said, in an old CPT Assistant, that generally modifiers are not appended to an unlisted code.

Payors have their own rules. For example, some payors will accept modifier 62 (two surgeons/co-surgery) on an unlisted code such as 64999 while other payors do not.

We would not append modifier 50 (bilateral procedure) to an unlisted code. Your base, or comparison code, should reflect modifier 50 and the associated increase in fee. The same is true for modifier 22.

We also would not append modifier 51 (multiple procedures) to an unlisted code. Let the payor take the discount.

Coding for Wound Surgical Preparation

Question:

When billing for the muscle flap codes 15733, 15731 etc., can we also code for the surgeon’s cleaning and prepping by debridement before closing the wound with a facial flap?

Answer:

Yes, the surgical prep codes (15002-15005) may be reported with those flap codes as long as the surgical prep service is provided, documented and medically necessary. CPT calls this “surgical preparation” not “debridement.”