FAQs on the Discontinued Use of Consultation Codes

The Centers for Medicare and Medicaid Services (CMS) discontinued use of consultation service codes 99241-99245 and 99251-99255 performed in the office and hospital setting as of January 1, 2010. This change does not mean that clinicians can no longer provide consultation services; it instead means that these services will have to be billed differently. Here are answers to the most frequently asked questions regarding the policy change.

Additional Resources Complete information on the revisions to the Consultation Services Payment Policy may be found in the MLN Matters® Number: MM6740 (PDF, 203K) on the CMS web site. For specific coding question not addressed in the FAQs or the MLN Matters Article 6740, the Heart Rhythm Society recommends that members contact their local Medicare MAC, FI or carrier at their toll-free number. Download Call Center Toll-free Number Directory from the CMS web site. The official instruction, CR6740 issued to Medicare MACs, FIs and Carriers regarding the Consultation Services Payment Policy may be found as an Adobe PDF document (243K) on the CMS web site. E/M documentation guidelines for Medicare services may be found on the CMS website at on the CMS website.

1. How will Medicare handle claims with the consultation codes for services rendered on or after January 1, 2010?
Effective January 1, 2010, Medicare contractors will deny and return claims for consultation codes 99241-99245 and 99251-99255 with a message indicating that Medicare uses another code for the services. If a patient is referred to your office for a consultation, you are now required to report an Evaluation and Management (E/M) code for a new or established office visit (99201-99215) that most appropriately describes the level of service provided. For consultation services provided in a hospital inpatient setting or nursing facility, you must report an E/M code for initial hospital care (99221-99223) that most appropriately describes the level of service provided.

2. How will the admitting physician be distinguished from other physicians who may furnish specialty care in the hospital inpatient setting?
CMS has created a modifier “A1” to distinguse the physician who oversees the patient’s care (principal physician of record) from other physicians. This modifier must be appended to the principal physician of record initial hospital care code. If you are not the principal physician of record and are providing specialty care, CMS requires you to use the appropriate E/M code (99221-99223) when the initial evaluation is performed. Follow-up visits in the hospital setting may be billed using subsequent care codes (99231-99233).

3. How will billing for the consultation codes crosswalk to the office visit and initial hospital care codes?
While the key components of history, examination, and medical decision making for some consultation codes perfectly crosswalk to certain office and initial hospital care E/M codes, CMS states that the mappings are provided for the purpose of establishing budget neutrality of the work relative value units (RVU) and are not intended as billing guidance. In place of the consultation codes, CMS increased the RVUs for new/established office visits and initial hospital/nursing facility visits, and incorporated the increased use of these codes into the practice expense (PE) and malpractice calculations. CMS also increased the incremental work RVUs for the E/M codes that are built into the 10-day and 90-day global surgical codes. Physicians must bill the appropriate E/M code based on the level of service provided.

4. Will the documentation requirements specific for consultation codes, including a written response to the referring physician, apply under the revised policy?
This requirement is not addressed in the policy; however, it is recommended that the documentation requirements for consultation services be continued to promote proper coordination of patient care. Also, maintaining the same documentation standards will substantiate billing for consultation services if a patient has a secondary insurer other than Medicare.

5. What constitutes a new patient?
By CPT definition, “a new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, “an established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.“ According to Medicare MLN Matters Article 6740 “a new patient is a patient who has not received any professional services (E/M or other face-to-face service) within the previous three years.” For further clarification on what Medicare constitutes as a new or established patient not addressed in the MLN Matters Article 6740, the Heart Rhythm Society recommends that members contact their local Medicare MAC, FI or carrier.

6. How will Medicare pay for a consultation service requested by another physician in the same group practice?
The policy states that Medicare may pay for an inpatient hospital visit or an office/outpatient visit if one physician in a group practice requests an E/M service from another physician in the same group practice when the consulting physician has expertise in a specific medical area beyond the requesting professional’s knowledge. The consulting physician must report the appropriate E/M code based on the level of service provided. The policy does not clarify whether or not a patient referred from a physician within the same group practice with a separate specialty designation (e.g., Internists) will enable the consulting physician to bill for a new patient visit vs. an established patient visit. For further clarification on what Medicare constitutes as a new or established patient, the Heart Rhythm Society recommends that members contact their local Medicare MAC, FI or carrier.

7. How will the new policy apply to claims in which Medicare is the secondary payer?
Consultation codes (99241-99245 and 99251-99255) will not be recognized for Medicare secondary payment (MSP) after January 1, 2010. In MSP cases, physicians must bill the appropriate E/M code based on the level of service provided. Since other third-party payers will continue to recognize consultation codes for payment, the policy states physicians may either:

• Bill the primary payer an E/M code for the level of service rendered and report the amount actually paid by the primary payer, along with the same E/M code to Medicare
• Bill the primary payer using a consultation codes and then report the amount actually paid by the primary payer, along with the appropriate level E/M code.

8. If Medicare denies a consultation service, what is the denial code? Should the physician bill the patient?
Claims for consultation services (99241-99245 and 99251-99255) provided after January 1, 2010 will be returned with a message indicating that Medicare uses another code for the service. The physician must resubmit the claim with the appropriate E/M code for the service and may not bill the patient for a non-covered service.