How to Get Medicare to Pay for Consults

CMS says to use E/M codes to report these services, but you’ll have to play by their rules to get paid.

By G.J. Verhovshek, MA, CPC,

Medicare stopped accepting claims for outpatient (99241-99245) and inpatient (99251-99255) consultations as of Jan. 1, 2010, but physicians haven’t stopped providing these services. How are they getting paid? After the 2010 Physician Fee Schedule (PFS) final rule was published, the Centers for Medicare & Medicaid Services (CMS) instructed physicians billing under the PFS to use other “applicable” evaluation and management (E/M) codes to report these services. Three years later, identifying which E/M code is most applicable is still a source of confusion for many. Let’s clear up that confusion here and now.

Follow “Regular” E/M Guidelines for Outpatient Services

Report outpatient E/M services with the appropriate Outpatient Services code (e.g., 99201-99215 for office outpatients). The service must be supported by the key components of history, exam, and medical decision-making (MDM)—or time, if counseling and/or coordination of care dominates the encounter.

For example, a surgeon sees a new Medicare patient in the office for a consultation for another provider in the area. The surgeon will bill the consultation visit as a new patient visit at the appropriate level using 99201-99205. For instance, to report 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components; A detailed history; A detailed examination; Medical decision making of low complexity, the physician would need to document, at a minimum, a detailed history, a detailed examination, and low-complexity MDM. Alternatively, the physician may report 99203 if counseling and/or coordination of care comprise 50 percent or more of a visit lasting 30-44 minutes, and the content of the visit is properly documented.

Don’t Forget the “Three Rs”

Although you cannot report CPT® consultation codes (99241-99245 or 99251-99255) to Medicare payers, the Centers for Medicare & Medicaid Services (CMS) instructs providers to continue to document the request, reason, and report for consistency and improved patient care.

Per MLN Matters® MM6740 revised, “Revisions to Consultation Services Payment Policy,” Dec. 14, 2009:

“Conventional medical practice is that physicians making a referral and physicians accepting a referral would document the request to provide an evaluation for the patient. In order to promote proper coordination of care, these physicians should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting physician. This is not to be confused with the specific documentation requirements that previously applied to the use of the consultation codes.”

Inpatient Services

Inpatient consultations should be reported using the appropriate Initial Hospital Care code (99221-99223) for the initial evaluation and a Subsequent Hospital Care code (99231-99233) for subsequent visits.

In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221). According to CMS guidance found in MLN Matters® SE1010 (revised), “Questions and Answers on Reporting Physician Consultation Services,” you may report subsequent hospital care codes (99231-99233) in these cases:

Q. “How should providers bill for services that could be described by CPT inpatient consultation code 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?”

A. “There is not an exact match of the code descriptors of the low-level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires ‘a problem focused history’ and ‘an expanded problem focused history.’ In contrast, initial hospital care CPT code 99221 requires ‘a detailed or comprehensive history.’ Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require ‘a problem focused interval history’ and ‘an expanded problem focused interval history’ and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.”

The same article assures providers that Medicare payers will pay for initial visits reported using subsequent care codes:

Q. “How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?”

A. “While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”

Modifier AI Distinguishes Among Providers’ Inpatient Services

When a Medicare patient is admitted, and another physician provides a consultation for that patient, a situation may arise in which both the admitting physician and consulting physician report an initial inpatient service (e.g., 99221-99223). To differentiate between the two physicians’ services, and to prevent a claims denial for duplication of services, the admitting physician should append modifier AI Principal physician of record to the initial inpatient service code.

For example: A patient presents to the emergency department (ED) with chest pain. The ED physician evaluates the patient and codes an ED visit (99281-99285). He also requests a consult from a cardiologist. The cardiologist evaluates the patient and decides to admit him. The admitting cardiologist would report an initial hospital visit (99221-99223) with modifier AI appended.

If the patient also has uncontrolled diabetes, and the admitting physician (the cardiologist) requests a consult from an endocrinologist, the endocrinologist might also select an initial hospital visit code, depending on the level of service she provides, to report her consultation. But the endocrinologist would not append modifier AI because she is not the admitting physician overseeing the patient’s overall care.

What if?

Per CMS guidelines, “In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.” For instance, if the cardiologist had not admitted the patient in the scenario above, she would have reported an ED visit because 99281–99285 are the best (non-consultation) codes to describe the service. For patients receiving hospital outpatient observation services who are not subsequently admitted to the hospital as inpatients, physicians should report 99217–99220, etc.

You can find complete guidelines with extensive coding examples in MLN Matters® MM6740 (revised).



G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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