Outpatient Consultations Billed with Other Services

HMSA is in the process of upgrading its claims processing system for private business claims. During the transition from old system to new, some claims will process using HMSA’s existing edits and others will process using the new claims processing system with OPTUM edits. Because HMSA is transitioning to a new system, it does not plan to incorporate the policy changes into the old system. As a result providers may notice small variations in processed claims, depending on whether the old system or the new system was used for processing.

The edits described below apply to claims processed under the new claims processing system. Nevertheless, HMSA suggests that practitioners adopt the guidelines when filing claims to HMSA for all private business claims.

The code edit changes described in the guidelines below will not override HMSA’s existing medical policies.

The following code edits apply to outpatient consultations (CPT codes 99241 - 99245) billed with other services.

Modifiers

When billing outpatient consultations with other services it is important to bill accurately. In some cases, a modifier code must be appended to the outpatient consultation code to ensure that both services are paid when appropriate. The following modifiers may be used for this purpose: 24, 25 and 57. Practitioners are urged to familiarize themselves with the criteria listed in CPT and the following policies.

• Modifier Code 25
• Modifier Code 57
• Preoperative Visits
• Postoperative Visits

Modifier codes should only be used when the service meets the criteria described in CPT and the policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

Specific edits

Surgery section

If an outpatient consultation is done in conjunction with any service listed in the Surgery section of CPT (codes 10041 - 69990), and the consultation meets criteria for the use of modifier codes 24, 25 or 57, the appropriate modifier should be appended to the consultation code.

The following surgical codes are frequently billed by providers without modifiers when paired with outpatient consultations. When these services are billed, if the appropriate modifier is not appended to the consultation code, the consultation may not be paid. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

1. When this procedure is billed, HMSA’s old claims processing system will allow payment only of the higher-valued procedure, either the visit or procedure. Under the new system, both may be paid if criteria are met.

Note: The list above is not all inclusive, but represents the codes in the Surgery section that are most commonly billed with outpatient services and to which these guidelines apply.

Radiology section

If an outpatient consultation is done in conjunction with the surface application of a radiation source (77789) from the Radiology section of CPT, and the consultation meets criteria for the use of modifier code 24, 25 or 57, the modifier should be appended to the consultation code. If the modifier is not appended, the consultation may not be paid.

Medicine section

For information about outpatient consultations billed with the administration of immunizations, see Immunization Administration Billed with Other Services. For information about outpatient consultations billed with the administration of injections, see Injections and Intravenous Infusion Billed with Other Services.

If an outpatient consultation is done in conjunction with other services from the Medicine section of CPT (codes 90281 - 99602), and the consultation meets criteria for the use of modifier code 24, 25 or 57, the modifier should be appended to the consultation code. If the modifier is not appended, the consultation may not be paid. Note: The presence of the modifier does not guarantee payment if the modifier is not applicable or other payment policies apply.

Note: The list above is not all inclusive, but represents the codes in the Medicine section that are most commonly billed with outpatient services and to which these guidelines apply.

Revision History