Some Clarification Given when Billing Consultation Codes

It has been a few months since Medicare officially announced they would no longer allow payment for the inpatient (99251-99255) or outpatient (99241-99245) consultation codes. The works RVUs for the consultation codes have been distributed to increase the work RVUs for the new and established outpatient, initial hospital and initial nursing facility visit codes.

To review:

·     Consultations provided in the physician’s office are to be reported using the new and established patient outpatient visit codes (99201-99215).

·     The initial hospital visit codes (99221-99223) are to be used to report the first consultation of the admission to the hospital.  The subsequent hospital visit codes (99231-99233) will continue to be reported for any follow up consultations or additional visits by the specialist during the same admission.

·     Consultations performed in the emergency department are to be reported using the appropriate ED code (99281-99285) or outpatient visit code (99201-99215).

·     Initial consultations provided in the nursing facility will be reported using the initial nursing facility visit codes (99304-99306).

·     The principal physician of record will append modifier “-AI” Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed.

·     However, claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.

What are the commercial payers doing?

Many payers are continuing to accept the consultation codes. However, some have announced eliminating them as well.  Review provider bulletins and website updates for your payers to determine specific guidelines. In addition, it is recommended that you review processes and procedures within your department to ensure coding and billing accuracy for all payers.

Even though consult codes are no longer reimbursed by Medicare, Medicare has recommended that physicians continue documenting the referral request and communication back to the referring physician.  Note that you may still need to adhere to consult guidelines for other payers.

How do I report consultations when Medicare is the secondary payer?

Medicare will no longer recognize the consultation codes for purposes of determining Medicare secondary payments (MSP). In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and others billing for these services may either:

·         Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or

·         Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

Additional information available: MedLearn Matters Article 6740, which can be found via The Coding Suite.

Written by: Gina Hobert, MBA, CHC, CPC-I, CECM, CMOM