Inpatient consultation CPT codes

[milomoneepood]

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My billing company said the HMO payer denied my claim with CPT 99222 on a patient in an acute care hospital that I billed for pain initial consultation level 2.

They’re advising resubmitting CPT 99233 (subsequent level 3 follow up) instead although it was an initial consultation. They’re saying the HMO payer denied it because the initial inpatient code (one of the 99221-99223) was already used by the hospitalist during inpatient initial admission H&P so the HMO will deny any other initial inpatient CPT codes.

What is my billing company missing? I know for a fact that my consultation colleagues (pain, cardiologists, physiatrists, pulmonologists, etc) at inpatient hospitals are billing either 99222-99223 for their inpatient initial consultations. (depending on the complexity). I would find another company but they’re also doing my credentialing so I can’t dump them just yet :/

 

[Orin]

Do you have a consult order to marry to the note? Is it post-op pain and is the surgeon the ordering physician? What's your billing base specialty and did someone else with that base bill a consult for that patient?

Agree with just taking the sbsq visit CPT but I assume you're not looking at inpatient consults as a money generator and are getting some other benefits for providing that service.

 

[Ducttape]

Did you make sure the billing company specified your specialty to the HMO?

I don't see why 99222 would not work if you are distinctly different specialty than hospitalist service.

Unless... did someone else with your specialty bill before you ( ie PMR consult and the billing company used that specialty and not Pain)...

 

[milomoneepood]

Do you have a consult order to marry to the note? Is it post-op pain and is the surgeon the ordering physician? What's your billing base specialty and did someone else with that base bill a consult for that patient?

Agree with just taking the sbsq visit CPT but I assume you're not looking at inpatient consults as a money generator and are getting some other benefits for providing that service.

Yes I had a pain management consult from the primary hospitalist team that was married to the note.

It was for a non-surgical fracture pain.

I told my billing company that the consult was for Pain, and even gave them my Initial Pain Medicine Consult note to bill for a 99222. With that said, I assume they used Pain Medicine/Pain Management as billing base specialty, but am not 100% sure. I need to ask them. I am PM&R/Pain but the billing company should still be able to bill under Pain specialty if Pain was what I did my consults in?

There was a separate PM&R consult service on the same patient when I was doing my Pain consult. Even with the separate PM&R consult service on, if my 99222 claim was billed for Pain I should be able to submit claim for my initial inpatient encounter?


I am working at a particular VA system where it’s known to not pay as competitively. But since they don’t have non-compete I am hoping to build consult services at outside hospitals in the community to generate additional income.

I just signed with this billing company and I am realizing that they don’t have much experience with submitting claims for inpatient consult services. Unfortunately they’re doing my credentialing for insurance payers so I can’t just switch to a new one yet… I’d really like my billing company to bill correctly and not miss out on anything because of their lack of knowledge. I am also learning as I go at this early phase of a fresh newbie attending career, so that I can properly advise my billing company to submit/appeal/change codes/etc.


Thank you!

 

[milomoneepood]

Did you make sure the billing company specified your specialty to the HMO?

I don't see why 99222 would not work if you are distinctly different specialty than hospitalist service.

Unless... did someone else with your specialty bill before you ( ie PMR consult and the billing company used that specialty and not Pain)...

I would have to confirm with my billing company. I am PM&R/Pain but for this specific 99222 it was for Pain consult. There was a separate PM&R consult service on the same patient when I did my consults. But that shouldn’t matter if my billing company specified my specialty as Pain to submit 99222, correct?

I don’t understand why my billing company is telling me to change to 99233 to resubmit for my initial consult for the reason of “this patient was already admitted a week before you started Pain consults on the patient; since an initial inpatient care code must have already been used for an admission H&P, you as a consult service can’t use another initial inpatient care code (99221-99223).”


Thank you!