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Medicare as secondary when consult codes were billed to primary carrier

Jaime Hinkle

Article Keywords: Medicare, secondary, consult code

Symptoms: Claim is sent to a primary insurance carrier with one or more consult codes (ranges 99241-99245
and 99251-99255) on the visit. Claim is then sent to Medicare as a secondary payer; Medicare denies payment
of consult code. 
Problem Description: As of January 1, 2010, the CPT consultation codes (ranges 99241-99245 and 99251-99255)
are no longer recognized for Medicare Part B payment. For dates of service on or after January 1, 2010, providers
should report each service with an E/M code that represents where the visit occurs and identifies the complexity of
the visit performed.

The practice has two options with visits that would usually be billed with a consult code where Medicare is a
secondary payer:

1. Bill an E/M code to both the primary and the secondary payers in place of the consult code when Medicare is the
secondary payer on the visit. NOTE: This is by far the easier solution to this issue, although the primary often pays
more towards a consult code than a comparable E/M code. 
2. Bill the consult code to the primary, then replace the consult code with a comparable E/M code before sending the
claim on to Medicare as secondary. NOTE: Medicare has assured HealthCo Information Systems that changing the
consult code to an E/M code does not constitute fraud, and is in fact required to process claims as secondary when a
consult code is billed to the primary. For more information, please contact Medicare directly for assistance. 
NOTE: HealthCo Information Systems can not advise practices on which of the above options is best for them. The
practice must weigh the payments received for E/M codes vs. consult codes against the time and effort it will require
to bill the claim to Medicare as secondary and determine which option is most appropriate. 
Resolution: To bill Medicare as secondary when a consult code was used to bill the primary:

1. Void the consult code on the visit and replace it with a comparable E/M code by completing the following steps:
a. Open the visit in question and click the Charges tab.
b. Right-click the consultation code on the visit and select Void Procedure.
c. If you do not have a default financial batch selected, you will be prompted to select a batch for voiding the
procedure. Select or create an appropriate financial batch for the procedure void. Once the procedure is voided,
it will appear twice in grayed out rows on the visit; one row will have a positive Quantity, and the other will have
a negative Quantity to cancel the first row out. Both rows should be unchecked automatically.
d. In an empty procedure row, enter the E/M code you are replacing the consult code with.
e. Double-click the E/M code to modify it.
f. Set the Fee for the E/M code equal to the fee on the voided consult code.
g. Click OK.
h. Click the Close to save and close the visit.
i. You will receive a prompt stating: This visit contains newly voided procedures. Once voided procedures are
saved they cannot be reversed. Are you sure you want to continue saving the visit? Click Yes to this prompt.
2. If a payment from primary was posted towards the consult code, convey the payment from the consult code to the
replacement E/M code by completing the following steps:
a. Open the visit and click the Trans tab.
b. When the consultation code was voided and the visit was saved, a new payment line from primary should
have been created automatically with a negative adjustment on the consultation code, backing any adjustment
the primary made towards the consultation code off of the visit. If there were multiple adjustments made by the
primary across multiple payment lines, then multiple negative adjustments should have been created. Scroll
down to the last payment line from primary (the negative adjustment) and double-click to modify it.
c. In the Payment column, post a negative payment amount in the row for the consultation code, and a positive
payment amount in the row for the E/M code.
d. In the Adjustment column, post a positive adjustment amount in the row for the E/M code. This should be
the total amount that the primary adjusted off of the fee for the consult code.
e. Re-enter the Line Information that was entered in the original payment from primary for all procedures
except for the consult code. Enter the Line Information that was originally posted to the consult code in the row
for the replacement E/M code. 
f. Click OK.
The claim should now be ready to be batched and sent electronically to Medicare as a secondary payer.

Related External Links:
CMS MLM Matters Number SE1010 regarding Medicare and consult codes:

HealthCo article on billing Medicare secondary electronically:

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Last Modified: 10 Months Ago
Last Modified By: braatene
Level: Aadvanced
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