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:
For Medicare products that Anthem administers only, Anthem follows Medicare guidelines and no longer recognizes consultation codes.
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:
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 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
|Aetna||Accepts Consultation Codes|
|Anthem—Commercial||Accepts Consultation Codes|
|Anthem—Medicare||Does NOT Accept Consultation Codes||01/01/10|
|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.