Medical Billing Modifier 56 Pitfall

Medical Billing Modifier 56 Pitfall

Using modifier 56 in a medical billing preoperative consult can be used by a specialist or even a primary care physician. Many people believe specialists are only allowed to perform consultations. This is incorrect thinking. If done correctly medical billing reimbursement is allowed for family care practice consultations.

There are two main situations in which a family care physician would perform a consultation in medical billing. The first, and the most common scenario, is when a surgeon requests that a family practice physician examines their patient prior to surgery. They would do this to make sure the patient is healthy enough to undergo the specific surgery.

The second scenario is when a patient requests a second opinion. If one primary care physician recommends surgery, that patient can seek another primary care physicians opinion. The second physician would be considered a consult in medical billing.

In order to correctly do medical billing for a primary care physician consultation, a few things must be present. The consult must be medically necessary. Also, either the patients themselves or another physician must directly request that consultation. Medical billing is not allowed for a consultation by a primary care physician unless someone else has requested it.

When the primary care physician is finished with the consultation, they must report back to the requesting physician with their opinions. To be reimbursed in medical billing, the consulting physician must have “An expertise and knowledgebase over and above the referring physician.”

As you can see, it is possible to receive medical billing reimbursement for a primary care physician consultation. There must be several factors present, and it must be medically necessary. However, if all of these requirements are met, you should have no trouble submitting medical billing claims to payers.

View all Articles by: Melissa C. - OMG, LLC. CEO