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January 25, 2018

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Medical Coding News Archives

Medicare Coverage for Consultation Codes Is History

November 10, 2009:

Consultation CPT codes will no longer be covered by Medicare, according to the Centers for Medicare and Medicaid Services (CMS). The agency has redistributed the value of the consultation codes across the other evaluation and management (E/M) codes for Medicare services.

CMS has retained values for codes 99241–99255 in the Medicare physician fee schedule for those private payers who use the data for reimbursement. Note that private payers may choose to follow CMS or CPT guidelines and the use of consultation codes should be verified with the individual payers.

In the 2010 physician services final rule, CMS stated that despite refinements to coding and documentation guidelines, consultations continue to be reported inappropriately. As a result of the confusion regarding consultations, CMS has adopted new policies regarding codes for these services. Under these guidelines the inpatient and office/outpatient consultation CPT codes will not be covered by CMS. However, Medicare will cover telehealth consultations when reported with the appropriate HCPCS Level II G code.

In past years, the guidelines regarding consultations have been revised and both the American Medical Association (AMA) and CMS have attempted to clarify them. Despite these efforts confusion regarding consultations, including the required documentation and appropriate use of the consultation codes, continues.

For 2010 the AMA included additional guidance in the CPT manual regarding consultations. A consultation is now defined as a service that a physician or other appropriate source must request so as “to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” CPT states that the request may be verbal but must be documented in the patient record “by either the consulting or requesting physician or appropriate source.” New guidelines also emphasize that a consultation initiated by the patient is not reported using the consultation codes.

CMS will also initiate additional changes regarding inpatient services in 2010. All outpatient services will be reported using the appropriate new or established E/M codes. The first inpatient encounter by any physician will be reported with initial hospital care codes 99221–99223, and subsequent inpatient encounters will be reported with codes 99231–99233. As only one physician may be the admitting physician, CMS has added HCPCS Level II modifier AI (Principal physician of record), to be appended to the initial hospital care code by the attending physician.

Deborah C. Hall
Clinical/Technical Editor


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