I work for a company that has on call surgeons. These surgeons get called into the ED to consult for patients who may need surgery. Of course, some are minor surgeries with 0- 10 day global and others are 90 day global. I know that Consults etc are done in the ED department and billed out. Our surgeons also do their own consult because we are a different "specialty". When we code a consult, Initial Hospital (MCR forces the use of these in place of consult codes), or Initial Observation, our claim is denied as "service already billed for and paid" however, we are not the ones who were paid (could be ED, or another specialist that was called). They tell us we must use subsequent codes. We were pondering the use of a modifier 25 when we bill our initial consults etc. due to us being a different entity. Modifier 25 is a muddy code in my opinion. I get the physician office use of it and the whole separate E/M code in those situations. But when the ED or another specialty (cardio etc) has also billed a consult, and we have actually done our own surgery consult, would a modifier play an important role in our coding/billing?

We also get a ton of 10 day globals in which we have performed a consult the DAY BEFORE the surgery, that are getting denied as well – insurance companies are telling us to use modifier 25 to get it paid. That just doesn’t seem right to me since the global doesn’t start until the day of surgery. And frankly, our E/M was all about the issue the patient has that requires surgery.

If anyone has anything educational they can point me to that would be great.

I appreciate any help I can get!