Billing Medicare as secondary when consult codes were billed to...

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Billing Medicare as secondary when consult codes were billed to...


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. If a payment from the primary carrier has been posted to the visit, it must be backed off of the visit as a negative conveyance. (If the payment from the primary has not been posted to the visit, please skip to step 2.)
a. Open the visit, go to the Transactions tab and double-click the payment from the primary carrier. Note the amounts in the Payment and Adjustment columns. 
 

b. Click the COB Information button, remove any numbers that were entered and click OK.


c. Click OK on the Transactions Distribution window. 
 
d. Click the Visit Info tab, select the primary insurance carrier and click Set Carrier.

e. Click the File menu and select Save. If prompted, specify a batch for the carrier to carrier transfer.

f. Go to the Transactions tab and click New. 
 
g. Enter the following information:
i. Source: Insurance
ii. Batch: Select a batch for posting the conveyance.
iii. Amount: Enter the negative of the amount the primary paid (i.e. if the primary paid a total of $50.00 towards the claim, enter -50.00)
iv. Method: Conveyance
h. Click New. 
 
i. Enter the negative payments and adjustments from the primary. The negative payment must be distributed the same way the primary payment was. Note: you do not need to manually enter the Line Information, COB Information or Actual Allowed amounts when posting the negative payment.
j. Click OK.

k. Uncheck the File Next box and click OK. 
 
l. Click OK.


2. Void the consult code on the visit and replace it with an appropriate E/M code.
a. Click the Charges tab of the visit. Make note of the fee charged for the consult code. (Note: You may need to scroll to the right in order to see the fee.) 
 

b. Right-click the consult code and select Void Procedure. If prompted, select a batch for voiding the procedure. 
 
c. On a new procedure line, enter the appropriate E/M code to replace the voided consult code. Please note: There is no direct crosswalk for consult to E/M code conversions. HealthCo can not advise you on what E/M code to use to replace the consult code. If you have questions on which E/M code is appropriate, please contact Medicare directly for assistance.
d. Double-click the newly added E/M code to modify it.

e. In the Fee field, enter the fee originally charged for the consult code.
f. Click OK. 
 

3. Post the payment from the primary as a positive conveyance. Apply the money they paid towards the consult code to the E/M code added in step 3.
a. Click the Visit Info tab and confirm that the primary carrier is selected. If it is not, click the primary carrier and click Set Carrier.
b. Click the Transactions tab and click New. 
 
c. Enter the following information:
i. Source: Insurance
ii. Batch: Select a batch for posting the conveyance.
iii. Amount: Enter the total amount the primary paid towards the visit.
iv. Method: Conveyance (Note: if you skipped step 1 because they payment was not posted to the visit, use Check here instead of Conveyance.)
d. Click New. 
 
e. Post the payment from primary with all of the information that is usually required when filing to Medicare as a secondary payer electronically, including payment, adjustment, actual allowed, line information and COB information (Payer Paid Amount). Post the payment and adjustment(s) that the primary applied towards the consult code to the replacement E/M code (i.e. if the primary paid $20 towards the consult code, enter that payment of $20 in the payment column for the E/M code).
f. Click OK. 
 
g. Uncheck File Next box and click OK.

h. Click OK on Payment Entry window. 
 

4. Set carrier and approve visit for filing to Medicare as secondary.
a. Click the Visit Info tab.
b. Select the secondary insurance carrier (which should be Medicare Secondary) and click Set Carrier. 
 
c. Click the File menu and select Save. If prompted, specify a batch for the carrier to carrier transfer. 
 
d. Click the File menu and select Approve. 
 
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: http://www.cms.gov/MLNMattersArticles/downloads/SE1010.pdf

HealthCo article on billing Medicare secondary electronically: https://hiskb.healthcois.com/KnowledgebaseArticle10258.aspx


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Details
Last Modified:Tuesday, November 02, 2010
Last Modified By: Jaime Hinkle
Type: HOWTO
Level: Aadvanced
Rated 5 stars based on 1 vote
Article has been viewed 1,502 times.
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