Fam Pract Manag. 2014 Nov-Dec;21(6):30.
Author disclosure: no relevant financial affiliations disclosed.
- Getting paid for consultation codes
- Obesity counseling as an incident-to service
- Foreign body removal from the eye
Getting paid for consultation codes
I understand that Medicare no longer pays for consultation codes. Is this now also true for private payers? I have been getting paid for consultations by some insurance plans, but I am seeing an increase in denials from others.
Consultation codes (99241-99255) remain a valid part of the CPT code set. As you noted, Medicare no longer pays for consultation codes. This may also be true for programs that incorporate the Medicare Physician Fee Schedule, such as the Children's Health Insurance Program. However, as far as I am aware, many private health plans still pay for services reported with the consultation codes. You may confirm payers' policies for consultations on their websites or by submitting an inquiry.
Obesity counseling as an incident-to service
Our practice was approached by a nutritionist who would like to engage in a collaborative practice agreement with our physicians to provide intensive behavioral therapy for obesity. The nutritionist would provide the services to our patients at her office and bill them “incident to” our physicians' services. Does this meet the Medicare requirements for incident-to services?
You should be concerned about reporting these services incident-to your physicians' services if they do not represent a continuation of the physician's plan of care for the patient, are not an expense to the physician, are not provided with the physician present in the office suite (where he or she can provide direct supervision), and are not provided by an employee of your practice as defined in Chapter 15, Section 60.1 of the Medicare Benefit Policy Manual. In addition, the Centers for Medicare & Medicaid Services says only the following providers may report face-to-face behavioral counseling for obesity (G0447): physicians in general practice, family medicine, internal medicine, obstetrics/gynecology, pediatric medicine, and geriatric medicine; nurse practitioners; certified clinical nurse specialists; and physician assistants.
Medicare may also cover behavioral counseling for obesity services when billed by one of the provider specialty types listed above and furnished by auxiliary personnel under certain conditions. These are specified under the regulation at 42 CFR Section 410.26(b) (conditions for services and supplies incident-to a physician's professional service) or Section 410.27 (conditions for outpatient hospital services and supplies incident-to a physician service).
Any agreements such as the one the nutritionist proposed to your practice should be reviewed by an experienced health care attorney to avoid unintended violations of state or federal statutes.
Foreign body removal from the eye
I recently treated a patient for foreign body of the eye. I removed a superficial foreign body from the interior upper eyelid with a cotton-tipped applicator. Should this be reported as an evaluation and management service, foreign body removal, or both?
Code 65205 is appropriate for reporting removal of a superficial conjunctival foreign body from the eye. No incision or specific instrumentation is required. If the foreign body was embedded in the conjunctiva, code 65210, “Conjunctival, embedded (includes concretions), subconjunctival, or scleral non-perforating,” would be appropriate for reporting the removal. The evaluation and management (E/M) services would be included in the prep work of the procedure, unless additional problems were addressed that required significant physician work that was clearly documented in the record. In that case, an E/M code may be reported with modifier 25.
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