Consult Your Payer for Consult Guide-lines

Medicare no longer accepts 99241-99255, but other payers may.

By Lindsey H. Daly, MSHA, CPC

As I write this, it has been over six months since the Centers for Medicare & Medicaid Services (CMS) stopped accepting CPT® consultation codes 99241-99245 (outpatient) and 99251-99255 (inpatient); however, not all payers have followed suit. Many non-Medicare payers still recognize consult codes for appropriately documented services. If you have not done so already, you would be wise to identify your payer consultation guidelines and code accordingly.

Recently, I surveyed payers in my area (Colorado) and most of them distributed a formal policy. You might locate this information in either bulletin or online newsletter format. Often the information is difficult to locate, however, and I’ve found contacting the payer directly is the best way to determine the policy. Locating the appropriate contact can be tricky as well, but by calling provider relations you should be directed to the right person.

To simplify your request, be prepared to ask the contact what the payer’s status regarding consultation code reimbursement is by referring to the CMS policy (available at www.cms.gov/MLNMattersArticles/downloads/MM6740.pdf). Often the provider relations contact will direct you to the online policy for your reference. If possible, e-mail the contact so you have additional documented information supporting the policy. Sometimes the provider relations contact does not respond to email, and documenting the details of the phone conversation is adequate (if not preferable).

After collecting the data, list each payer and its policy on consultation codes. For example:

Health Plans No Longer Recognizing Consultation Codes

Physicians’ Ally, Inc. has phone or e-mail confirmation that the following health plans no longer recognize consultation codes:

—  Anthem—Medicare

For Medicare products that Anthem administers only, Anthem follows Medicare guidelines and no longer recognizes consultation codes.

—  Colorado Medicaid

As of April 1, 2010, Colorado Medicaid no longer accepts consultation services. This affects CPT® consultation inpatient CPT® codes 99251-99255 and office/outpatient consultation CPT® codes 99241-99245.

Health Plans Continuing to Recognize Consultation Codes

Physicians’ Ally, Inc. has phone or e-mail confirmation that the following health plans continue to recognize consultation codes:

—  Aetna

Since the American Medical Association (AMA) still lists “consult” codes as active in CPT® 2010, Aetna and Cofinity continue to accept and price these codes as valid after Jan. 1, 2010. This is subject to future change, however.

—  Anthem—Commercial

Anthem is not following Medicare’s lead on the consult codes for commercial reimbursement. However, Anthem is discussing a new fee schedule update for Jan. 1, 2011.For easy reference, refer to Table 1 for a quick-view summary of each payer’s guidelines.

Table 1: Payer Reimbursement—Summary

Payer Status Effective
Aetna Accepts Consultation Codes  
Anthem—Commercial Accepts Consultation Codes  
Anthem—Medicare Does NOT Accept Consultation Codes 01/01/10
CHP+ Under Review  
CIGNA Accepts Consultation Codes  
Colorado Access Does NOT Accept Consultation Codes 03/05/10
Colorado Medicaid Does NOT Accept Consultation Codes 04/01/10
Denver Health Accepts Consultation Codes  
Humana—Commercial Accepts Consultation Codes  
Humana Medicare (MCHMO and MCPPO) Does NOT Accept Consultation Codes 01/01/10
Rocky Mountain Health Plans Does NOT Accept Consultation Codes 04/01/10
UnitedHealthcare—Medicare Solutions Does NOT Accept Consultation Codes 01/01/10
UnitedHealthcare Commercial Accepts Consultation Codes  

This is the most recent information available for these payers in Colorado. Be sure to research your specific payer guidelines; and be aware that rules change. It is important to look for notifications to determine when or if health plans will no longer recognize consultation codes.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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