Q A patient’s insurance company bundles an ultrasound procedure with a consultation, and quotes Medicare rules as the basis. For instance, we bill 99242 (Office consultation; expanded problem focused history and exam with straightforward medical decision-making) with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and the services are being provided by a maternal-fetal specialist.
I have appealed many times, but they refuse to pay for both. Do you have any suggestions?
A My first suggestion is that you inform ACOG’s Department of Practice Management about this problem. For more information, see http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=1932. ACOG has been helpful to many practices in the past on just such payment issues.
The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.
In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.