My provider was on call at a facility and looks like he saw a pt for initial consultation. The next day he assisted in surgery for this pt. Aetna denied the 99254 as global and the 49204 reason denial is N674-Not covered unless a pre-requisite procedure/service has been provided and also B15-This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Looked in cpt book but doesn’t state anything should be done additional for this surgery. I am thinking its the pts policy and coverage but rep told me just to send medical records. Any idea what this pre requiste procedure/service could be?
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Tag Archives: Initial
Diagnosis codes for Initial hospital care and subsequent care?
Can we report same diagnosis codes for subsequent care form Initial hospital? Please advice.
Initial vs subsequent vs sequela
If a patient was treated in a nearby ER or Hospital for a bone fracture, and then comes to an internal medicine office as an established patient to be treated for the bone fracture, is the fracture treatment/evaluation considered an initial or subsequent visit to the internal medicine office? In other words, is it initial or subsequent if it is the first time patient is in the office for the bone fracture that was diagnosed and evaluated at the nearby ER?
Sequela is late effects so how many months/years need to go by when a subsequent visit/illness becomes a sequela?
thank you
Sequela is late effects so how many months/years need to go by when a subsequent visit/illness becomes a sequela?
thank you
Initial vs Subsequent in Hospital setting
I’m very confused when to use initial vs subsequent when a patient is in the hospital– do we only use A for fist initial visit then switch to D for remainder of stay, or do we use A for entire time frame of hospitalization as we’re "actively" treating a fracture etc?
Res Only Initial Admit into Hospital. Can this be done?
I have a claim where the Resident did the HPI, ROS, PE, & listed the diagnoses, signed the note. However, the Physician did not attest to this Initial admit, and signed the note 2 days later. Can I bill this claim as a Res Only Admit?
Under Michigan’s New Medicare RAC Regime, Physician Services Are the Initial Primary Target
An announcement came back in back in October 2016 from the Centers for Medicare & Medicaid Services (CMS). It announced that it had awarded to various entities the next round of contracts to serve as Recovery Audit Contractors (RACs) for their Medicare program. In totality, five separate RAC contractors were awarded. Each one was connected with one of the five designated “RAC Regions.”
The post Under Michigan’s New Medicare RAC Regime, Physician Services Are the Initial Primary Target appeared first on The Coding Network.
Initial Nursing Facility Care EM
A physician is taking over care of a patient that has already been a resident in a skilled nursing facility for more than 60 days. The provider bills the first encounter (which is establishing care) with the patient as a 99305. Is this okay or should the provider bill a different code?
E/M Consult, Initial Hospital, Initial Observation denials and modifier 25
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!
Wiki Two Initial Visit for Medicare
Can we bill two initial inpatient visit, if the patient is admitted by provider belong to one specialty and bill for 99223. On the next day, he consulted a physician of different specialty of the same physician group and he provided the service to the patient. Since the insurance is Medicare, they will not pay for consultation code. Should we choose 99221-3 as this is the first visit for the physician or 99231-3, since they belong to same group?
Initial or Surveillance for birth control pill change
A 17 year old patient was prescribed birth control pills for the first time and the diagnosis code used was Z30.011, encounter for initial prescription of contraceptive pills. The patient experienced side effects so a new prescription for a different pill was prescribed at her 3 month follow up. Is Z30.011 appropriate since it is a new prescription and pill type or would Z30.41, encounter for surveillance of contraceptive pills be correct?
After the initial prescription is written, is it ever appropriate to use Z30.011 again (e.g. whether repeat prescription or new pill type prescription at the ensuing annual visits)?
Thanks!