Inpatient consultation CPT codes

[milomoneepood]

Cross-posting from Pain because I am building consultation services in PM&R and Pain at hospitals (acute care hospitals, LTACH, IRF)

I recently did my first inpatient consult on a HMO patient in an acute hospital and submitted claim with CPT 99222 (level 2 inpatient initial encounter) for the initial consultation encounter.

My billing company just got back and said the HMO payer denied my initial consult claim CPT 99222 so they advised 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 during that hospitalization.

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 :/

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[RangerBob]

Cross-posting from Pain because I am building consultation services in PM&R and Pain at hospitals (acute care hospitals, LTACH, IRF)

I recently did my first inpatient consult on a HMO patient in an acute hospital and submitted claim with CPT 99222 (level 2 inpatient initial encounter) for the initial consultation encounter.

My billing company just got back and said the HMO payer denied my initial consult claim CPT 99222 so they advised 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 during that hospitalization.

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 :/

Your biller may have billed a 99222-AI. The AI designates the attending physician, hence it can only be used once. You should absolutely be able to bill a 99222. If your biller truly billed that, then then should appeal the denial. To my knowledge, the only reason a 99222 would be an issue is if another PM&R physician billed for a consult already.

Per my billers, we're seeing more denials, often for trivial things. The more insurance denies, then more likely they are to keep their money (because billers give up) or keep their money longer (if notes need to be sent, that lets them get another x days of interest accrual).

Still, I'm a little surprised your billers are telling you to bill a 99233.

 

[milomoneepood]

Your biller may have billed a 99222-AI. The AI designates the attending physician, hence it can only be used once. You should absolutely be able to bill a 99222. If your biller truly billed that, then then should appeal the denial. To my knowledge, the only reason a 99222 would be an issue is if another PM&R physician billed for a consult already.

Per my billers, we're seeing more denials, often for trivial things. The more insurance denies, then more likely they are to keep their money (because billers give up) or keep their money longer (if notes need to be sent, that lets them get another x days of interest accrual).

Still, I'm a little surprised your billers are telling you to bill a 99233.

Thank you for your answer! There was a general PM&R consult service on the patient separately. Although I am PM&R/Pain, but my service consult on this patient was for Pain Medicine and the encounter notes were written for Pain only and not PM&R. Would it matter for my billing as Pain consult if there was a separate PM&R consult service?

I will ask my biller about the AI modifier, and If so I will ask them to submit appeal without the AI modifier. In case they did not use the AI modifier, then I still tell them to appeal without 99222? What additional things would they need?

This billing company isn’t experienced in billing for inpatient consults, so I am learning with them. Currently I can’t just switch them because they’re also doing my credentialing with insurance payers ugh

Thank you again.

 

[RangerBob]

Thank you for your answer! There was a general PM&R consult service on the patient separately. Although I am PM&R/Pain, but my service consult on this patient was for Pain Medicine and the encounter notes were written for Pain only and not PM&R. Would it matter for my billing as Pain consult if there was a separate PM&R consult service?

I will ask my biller about the AI modifier, and If so I will ask them to submit appeal without the AI modifier. In case they did not use the AI modifier, then I still tell them to appeal without 99222? What additional things would they need?

This billing company isn’t experienced in billing for inpatient consults, so I am learning with them. Currently I can’t just switch them because they’re also doing my credentialing with insurance payers ugh

Thank you again.

Unfortunately I don't know the correct answer if PM&R already saw the patient. I believe if you're a difference service that you can still bill a consult code, but if you're both PM&R it's possible you cant.

I had thought in residency that our pain PM&R team couldn't bill separate/in addition the primary team. But if a hospitalist and cardiologist both can bill the same day (they're both IM the same as you're both PM&R), that wouldn't make sense...

The reality is if you can't bill a consult code, then you can't typically can't be billing a follow up either. Usually if the argument it "someone from your service already did a consult" then "someone from your service wrote a progress note that day" applies as well.

As far as what's needed for the consult, I'm not sure. My billers handle all of that. I would hope an explanation or perhaps the consult note are enough to show you did a consult, why it was indicated, and that you aren't the primary team.

 

[milomoneepood]

Unfortunately I don't know the correct answer if PM&R already saw the patient. I believe if you're a difference service that you can still bill a consult code, but if you're both PM&R it's possible you cant.

I had thought in residency that our pain PM&R team couldn't bill separate/in addition the primary team. But if a hospitalist and cardiologist both can bill the same day (they're both IM the same as you're both PM&R), that wouldn't make sense...

The reality is if you can't bill a consult code, then you can't typically can't be billing a follow up either. Usually if the argument it "someone from your service already did a consult" then "someone from your service wrote a progress note that day" applies as well.

As far as what's needed for the consult, I'm not sure. My billers handle all of that. I would hope an explanation or perhaps the consult note are enough to show you did a consult, why it was indicated, and that you aren't the primary team.

I did get paid for the same patient for the follow-up encounters….

would it be possible to share the contact info for your biller? it sounds like i’d need to look for another company when I am able to. It’d help to have a company who has experience working with physiatrist(s) and also inpatient consults for billing.

I can only do this so much to correct my billing company when I’m paying them to be the expert in these processes.

Thank you!

 

[RangerBob]

I did get paid for the same patient for the follow-up encounters….

would it be possible to share the contact info for your biller? it sounds like i’d need to look for another company when I am able to. It’d help to have a company who has experience working with physiatrist(s) and also inpatient consults for billing.

I can only do this so much to correct my billing company when I’m paying them to be the expert in these processes.

Thank you!

That is odd you got paid for follow ups but not the initial consult.

Inpatient billing is very simple and straightforward for billers. There are only so many codes they have to deal with. I can send you a PM with my billers contact info, but as far as I know they have a full client load right now.