Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written report back to the patient’s requesting physician.

The delivery of physician services may be getting close to a technology tipping point – after all, a recent Information Week report suggests even telemedicine will be a $27 billion business by 2016.

But these new codes are likely to be another instances where the technology – and the availability of the codes for billing and tracking – is ahead of the world of payment. So far, Medicare slapped the new codes with a payment status indicator of B – making them bundled into all other services – and there is no evidence that any other payers see them any differently.

It’s unclear whether the time spent on these service could truly be “bundled” into a face-to-face encounter, given Medicare’s refusal to pay for non face-to-face care. At least not yet.

The four codes are based on the amount of time spent on the service, and are intended for use by the provider being consulted. 99446 is for between 5-10 minutes of time, 99447 for 11-20 minutes, 99448 for 21-30 minutes and 99449 for more than 31 minutes.

The time counted toward the services are medical consultative discussion and review time spent by the specialist. These new codes are different from the 99441-99444 set created in 2008 for phone or Internet E/M services with the patient because they are intended to cover discussions between providers.

If a payer allows you to bill these codes, or to consider the time spent as part of a bundle into a different E/M face-to-face encounter, remember these rules that govern their use:
• Discussions of less than five minutes are not reportable.
• The patient may be a new or established patient to the specialist, but must not have seen the specialist face-to-face in the previous 14 days or the following 14 days.
• Discussions initiated to facilitate a known transfer of care may not be counted.
• If more than one phone conversation is needed, the calls are bundled into a single code for reporting purposes.
• Like a consult, the request for the specialist’s opinion and the ultimate report back needs to be documented in the patient’s record.
• These services are intended for urgent or complex cases where a face-to-face visit with the specialist may not be possible.
• This service should not be reported more than one time per patient over a seven-day period.

Author: Scott Kraft

– Source: http://codapedia.com/article_715_Don%E2%80%99t-expect-to-see-payment-any-time-soon-for-%E2%80%98telephone-consults.cfm#sthash.n4HT6fRv.dpuf

For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following:

• There must be written documentation in the chart from the physician practice requesting the consult. You can have them fax a request or the patient can bring it with them, but as the physician billing the consult, you have to make sure you have the request in writing.

• The written report that must be sent to the requesting physician is the most often overlooked component of a consult code. This report does not have to be a full copy of the history, exam, and decision making but can be a summary of your opinion and recommendation for treatment. Most requesting providers would prefer not to have the full consultation note; it’s too much reading; duplicates information they already have in their own history, and takes up too much space in the chart. Make sure you maintain documentation in your chart that shows that the opinion was sent either by mail or fax or email.

• Primary care or cardiology physicians who are asked to clear a patient for surgery can bill a consult code, even if the clearance is for an established patient. Remember that for Medicare patients, surgery clearance is only covered for patients with an underlying medical condition such as hypertension or diabetes that must be managed to safely perform surgery. Most carriers suggest the use of V72.83 diagnosis code for pre-operative surgery clearance. Remember that the requirements for written request from requesting physician and the need to send back your opinion to the requesting physician still apply.

• Medicare has made it very clear that consults CANNOT be shared between non-physician practitioners and physicians. If a non-physician practitioner performs any of the key elements of the consult, then the consult cannot be billed under the physician NPI. For commercial carriers, be sure and find out if these visits can be shared–don’t just assume that they can.

Once you get your processes in place to ensure you are following the rules for consult coding, you can put more energy into patient care. Happy coding!

Author: Kay Stanley

- Source: http://codapedia.com/article_321_Consult-Documentation-Guidelines.cfm#sthash.Jh37oADa.dpuf

Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure?
In many cases outpatient procedures and surgeries do not require pre-authorization or precertification, but that does not guarantee payment by the insurance company. Insurance companies frequently require patients to meet criteria prior to having surgery. What is the difference between pre-authorization, pre-certification and pre-determination?
Pre-authorization is getting approval or permission for the procedure or surgery. Without the permission, the insurance company may not pay for the procedure. This may include learning the patient’s benefits or allowances for such procedures.
Often, physical therapy, occupational therapy and chiropractic services require approval prior to beginning of the services. An MRI or CT often requires approval from the insurance company. Without the prior approval when required, the insurance company won’t pay. As physicians staff members, it may be our responsibility to gain the approval.
Pre-certification is the gaining of approval from the insurance company by proving medical necessity. Often this is done by having the insurance company review documentation and medical records regarding the treatment to date of the patient. The goal here is for the provider to prove that the procedure is medically appropriate and needed. Insurance companies are looking to save money by requiring more conservative treatment prior to surgery.
Spinal and fusion surgeries are one of the procedures that insurance companies are looking to have patients do more conservative treatments prior to undergoing surgery. When a policy reads that the patient must undergo 6 months of physical therapy and a provider chooses to perform the surgery after 4 months of therapy, the insurance company most likely won’t pay for the surgery. Simply stated, the patient did not meet criteria. It does not matter how much pain the patient is in. Nor does it matter how many pain medications the patient takes during the day; the patient did not do what the insurance company required. Physician practices should fight on their patients’ behalf for the precertification when indicated whether or not the criterion has been met. They also need to be prepared to have some requests denied.
Who is left with the unpaid balance? More than likely the practice would not be paid. Most patients do not have the money to pay out of pocket for surgeries. We often forget that it is not only our bill that isn’t paid; the hospital, the anesthesiologist and all other bills will be denied by the insurance company.
Patients need to meet “medical necessity.” For most medical procedures, meeting medical necessity should be straightforward with proper conservative treatment and documentation provided the patients and providers follows the insurance guidelines and requirements. The most difficult (if not impossible) cases to prove medical necessity are for cosmetic surgeries.
For questionable coverage of a procedure or surgery, a practice may request a “predetermination of benefits” from the insurance company. What you are asking for is a written verification of the policy benefits and whether a specific procedure is covered by a patient’s insurance. Often this is done for procedures that may be considered experimental or not proven. A surgery does not need to be experimental for a carrier to label it as such. Knowing what is covered allows a patient to maximize their benefits and know up front what should or should not be covered.
Predetermination also allows the insurance company (most often by a physician) to review the patient’s records to determine whether the insurance carrier considers the requested procedure to be medically necessary.
Failure to do your due diligence prior to a procedure will often result in non-payment. Precertification, pre-authorization, predetermination and benefit verification will allow for better reimbursement of the procedure or reimbursement at all. Providers as well as patients need to be aware of their contractual agreements with the insurance carrier for the best opportunity for reimbursement.

Author: Donna Weinstock

- Source: http://codapedia.com/article_727_The-Benefit-of-Checking-Benefits.cfm#sthash.t1945K8w.dpuf