MEDICARE DENIAL SCENARIOS

MEDICARE DENIAL FOR CONSULT CODES 

Q: I have some questions relating to what we do to deal with Medicare not paying for consult codes. Please look at some scenarios below where I am not sure how to bill.

First scenario: Patient A arrives at the ER with an issue and he’s admitted to observation status by the hospital, the attending hospitalist who sees the patient in the ER codes the initial observation code because he’s the attending. Is this correct?

A: Use the initial observation codes if that is what you are doing. The only relevance the consults have here would be if the patient was not admitted. Then you’d have to use emergency department codes for the ER “consult.”

All the other physicians who provide consultations or additional assessments or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service.

MEDICARE CHART AUDIT 

Q: When Medicare asks to see charts for some kind of review, is there a way to know exactly what the problem is?

A: There’s no answer that covers all the possibilities, but the place to begin is with the request. They’ll usually give you some type of reason behind the review, a general category like documentation, medical necessity, or a program like CERT, MUE, NCCI, or RAC. If you’re speaking about a request for documentation review, you can tell a lot simply from the number of charts they request.

A request for somewhere between five and 15 charts is frequently just a probe sample. There’s no specific goal or issue of interest, it might be just a general audit to find out if there’s a problem with documentation, coding, or other current issues of concern.

When the number of required graphics arrives somewhere in the range of 15 to 50, then it’s pretty sure that the payer has some specific target an idea that some type of infraction has occurred or is occurring plus they would like to have a sense of frequency or severity.

If a sample is between 50 and 100 charts, it’s likely that someone on the payer end has a fairly clear idea of what the infraction can be, and is seeking a statistically valid sample possibly to start calculating damages or repayments.

So in a sense, you can tell something about a problem from the request. More related to the scope of the problem than the exact subject. And do not forget to call and simply ask.

CODING FOR UNUSUAL SERVICES –

Q: What are the most typical and acceptable codes I may use to complement my normal visit codes? I hear about all sorts of other codes, but do not want to do anything which will either burden my patients or cause a problem with insurance agencies.

A: There are a variety of CPT codes, some newer, some older, that providers may use to represent either unusual or some specific circumstances or services. Some of the services are listed below:

  • Advanced care planning
  • Transitional care management services
  • Smoking cessation counseling

 Facing a coding conundrum? We are here to help. Send your questions to support@skillacquire.us . Our Support team will help you to demystify your confusions. 

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