It’s Official: CMS Says Consult Codes are History

The Centers for Medicare & Medicaid Services communicated to Medicare carriers yesterday that consultation codes (99241-99245 and 99251-99255) have been removed from the Medicare Claims Processing Manual. Effective, Jan. 1, 2010, consult codes will no longer be recognized for Medicare Part B payment.

We first learned of CMS’ intentions to eliminate the use of consultation codes (with the exception of telehealth consultation G codes) in both inpatient and office/outpatient settings in the 2010 Medicare Physician Fee Schedule (MPFS) final rule (CMS-1413-FC). This news created such an uproar among health care professionals, industry experts entertained the idea of an appeal.

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Despite attempts to negate this policy change by stakeholders, including the American Medical Association (AMA), CMS makes the policy change official in Transmittal 1875, Change Request 6740, issued Dec. 14.

CMS will increase the work relative value units (RVUs) for new and established office visits, as well as for inpatient facilities, and incorporate the increased use of these visits into the practice expense (PE) and malpractice calculations. CMS will also increase the incremental work RVUs for the evaluation and management (E/M) codes that are built into the 10-day and 90-day global surgical codes.

For evaluation services performed in the office or other outpatient settings with dates of service on or after Jan. 1, 2010, physicians and qualified non-physician practitioners should use CPT® code range 99201 – 99215 according to current E/M documentation guidelines.

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This, however, may not be the final word. Of late, U.S. Senator Arlen Specter has proposed an amendment  to temporarily delay the policy change.


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40 Responses to “It’s Official: CMS Says Consult Codes are History”

  1. Kim Miller says:

    Medicare is eliminating consultation codes. Medicaid has not made a ruling in Ohio and commercial payors will continue to recognize the codes.

    I think we need to be clear on the issue.


  2. Christie Thomas says:

    How will we handle billing for Medicare secondary if we bill a consult to a primary insurance that still recognizes the consult codes?

  3. Nadine says:

    I agree. If the provider bills the codes to Medicare and they roll to Medicare Supplement carriers, the code will pay. I can also see a potential problem with billing E & M codes to Medicare but refiling a corrected claim to Commercial and receiving dual payments for the same service.

  4. Dawn says:

    So what codes will we use for a consult in the ER or Hospital? The Initial Care codes?

  5. Erica Schwalm says:

    I sent this memo to my docs today;thought I’d share (I’m in MA). Feel free to use…

    2010 Changes to Inpatient Hospital Billing

    No More Consults for Medicare Patients

    CMS will no longer recognize consultation codes (99251 – 99255) beginning January 1, 2010. The resultant savings will be redistributed to increase payments for the other E/M codes (i.e., new and established office visits, initial hospital, and initial nursing facility visits).

    So what do you do when you’re asked to consult on a patient?

    CMS says you may now bill an initial hospital care code (99221 – 99223). These codes will no longer be limited to the admitting physician and more than one physician can report these codes. In fact, CMS’s new policy states “In the inpatient hospital setting all physicians (and qualified nonphysician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221 – 99223)”.

    Therefore, any first visit with a Medicare inpatient may be billed with an initial code (if minimum requirements for codes are met). This is not limited to specialists.

    In order to differentiate between the admitting physician’s claim and other provider’s claims, CMS has created a new modifier, “-AI”. This modifier must be appended to the admitting physician’s initial hospital care code.

    Choosing the correct code

    There are five inpatient consult codes but only three initial care codes. The biggest problem is with the two lower level consult codes (99251, 99252). The remaining three (99253 – 99255) crosswalk nicely over to the initial care codes (99221 – 99223), with the exception of the “typical times” established for these codes. However, there are coding measures in place to account for situations of extended face-to-face time with patients (prolonged service codes).

    As for the low-level consult codes, 99251 and 99252, a consultant has two options: report an unlisted E&M code (99499) or report a subsequent hospital care code (99231 – 99233). CMS states “physicians shall bill the available code that most appropriately describes the level of the services provided”. Due to the administrative burden of using unlisted codes (dropping to paper, submitting with notes), I suggest the latter option.

    You may use the following crosswalk to report your consultation services to Medicare:

    Performed & Documented Bill Instead

    99251 99231
    99252 99232
    99253 99221
    99254 99222
    99255 99223

    Consults in the ER.

    If you are called to the ER to consult on a patient and you do not admit the patient, use the appropriate Emergency Department Services code (99281 – 99285).

    What about the other payors?

    As of December 16, 2009, BCBS of MA and Connecticare reps have stated their companies will be following CMS guidelines but no official policy has been released from either company yet.

    The remaining companies contacted have either stated they will not be changing their current policies or a decision has not yet been made.

  6. Nina Leeth says:

    Most of the Medicare supplements I have worked with in the past did NOT pay for services that were not covered by Medicare. Additionally, most commercial payors tend to follow Medicare’s lead, especially if it is going to save them money.

  7. Christina says:

    What do most of your office plan to do.
    Follow Medicare guidelines for ALL insurances or bill each carrier differently?
    How confusing it will be to Doctors to have to know which code can be billed.
    Also, there are carriers out there that do not follow Medicare guidelines and if Medicare denies, they will pay.

  8. Tia says:

    After much review, our speciality office (OB/GYN) in IN has decided to eliminate all consult billing to Medicare/Medicaid/all commerical payers after Jan 1, 2010. I’m sure it will not be very long before Medicaid and commercial payers will follow suit with Medicare, and to avoid that problem, we will be billing E/M codes 99221-99238 for Inpatient initial visits and subsequent visits. I was advised at a meeting last week that as far as the ER/OBS consults go, you should use the E/M codes 99203-99214 and your Dr. will have to inform you if the patient is new or established. ER visits 99281- 99285 should only be billed by the specialist, if the ER doctor did not see the patient. Most carriers will only pay for 1 ER E/M code and the ER doctor has to bill from those codes.

    If anyone else has any new information, please let everyone know by posting it. It seem information is changing daily, and since we are all in this together, lets share information.

  9. Michelle says:

    Several of our commercial carriers will continue to pay for consult codes beyond 1/1/10. It is not clear at what point they may no longer cover consult codes. It is not possible to bill different E&M codes to primary and seconday. It will be Medicare rules if they are primary and up to the physician when Medicare is secondary to bill consult and w/o any patient responsibility or bill per Medicare guidelines all the way around. The additional monies are by no means being redistributed to the other E&M codes. We have been told that the adjustments being made to these codes will increase by 5% or less. In an inpatient setting the consult to exisiting patient visit codes are more than double the reimbursement. This ultimately is going to make it very difficult to get specialists to perform consult/visits at all.

  10. Debbie says:

    The comments I’m reading are much calmer than the comment I have !!
    This is unbelievable. This will ding my doctor approximately $50.00 per patient.
    Even if there’s a 5% rate increase, there will still be a substantial price cut.

    I’d like to know what prompted this? Was it budget cuts, or did our politicians need
    to work on their Chrismas bonuses early?

  11. Christina says:

    I work for a Specialist and you can’t imagine what the consult code changes will do to our bottom line. We have a plan to have to let three people in our billing department go when this goes into effect because the money won’t be coming in any longer, nor does it even begin to cover the cost of the time put into a consult appointment, especially if you are an oncologist!

  12. Christina says:

    I think what prompted this, was the misuse and abuse of the consult codes. CMS and the individual Medicare carriers tried to educate the physicians on Conult guidelines, and I think they believe they are being abused,so by eliminating them, it takes the use and abuse out of the equation.

  13. Christina says:

    If you read what the RACs are beginning to look at and the reviews of consult codes the percentage of incorrectly coded consults is very high. The failed education and correct use of these codes has prompted what we are facing now!

  14. Roy says:

    It is next to impossible to know when it is consult an dwhen it is tranfer of care. 75% of the docs don’t care and if it is in large institution they are even worse because they don’t need to bother and if in private practice, the bottom line is dependent on consult billing an dthey err to overdo those. On specialist told me, he never billed a E/M in 10 yrs. So I guess they brought it on themselves. I feel sorry for the small majority that played by rules.

  15. Barbara says:

    Anyone know what the modifier will be that the specialist will use for inpatient visits? To date, when more than one physician bills for a visit the guy who gets it in first gets paid. Now it looks like we will all be using the same codes. What modifiers will we use and who will use them?

  16. Catherine says:

    Our MD does exams in nursing homes for medical eye problems without the use of consult codes what are we to use. This is a needed services to seniors that will have to be stopped, this seems unfair to them

  17. Arlene says:

    Everyone is complaing about their bottom line with the money not coming in for the consults. These codes have being used and abused. I thought the Doctors were working by taking care of the patients. The money is good, but what about the patients? Isn’t that the first priority of the Doctor and not how much money they can make?

  18. Jo Bowen says:

    Aetna has no plan at this time to remove Consult codes for PA or NJ and IBC is the same for PA. However we all know that most Insurances will follow Medicare at some point. I have to disagree with the crosswalk of 99251 and 99252 going to 99231 and 99232. As you know Initial visits require all 3 components where the follow up codes only require 2. My Physicians have reviewed the requirements of the Initial codes and it was their opinion that the amount of information they have to process in the first visit would almost always meet level 3 or higher. Medicare is also expecting Specialists to maintain a written order for Initial visit requests even though the Initial visit codes (in wording) do not require this aspect as Consult codes did. For Out-patient we are told by Medicare that scripts are not required for a patient visit since the coding for 99201 – 99205 does not require a written order. As far as supplemental Insurances: AARP, Horizon BCBS, GEHA, GHI, UHC, Highmark have informed us the Corrective claims will not be processed. The codes billed to Medicare are the codes they will process. You can’t have 2 fee schedules and they will only pay what Medicare has allowed. The 2010 fee schedule for PA and NJ for the new code sets has actually gone down (so much for applying the consult revenue to other E&M’s.) This should prove to be an interesting year.

  19. Sandy says:

    When checking the 2010 cpt codes on the Medicare website, all of the office visit codes we use went down; not up as we were told. This is a small practice and I can see alot of smaller practices having to close or merge with others in order to stay afloat.

  20. Susan says:

    CMS has cut consults and the so called increase in the other E&M’s did not happen. Those codes have been cut. I cannot find any information as to BCBS of GA, Aetna or UHC confirming they too will drop the consult codes.
    Between filing Medicare secondary for a consult that commercail carriers pay is an exercise in futility. I think a revision of the definition of the consult codes would have been a better idea, but hey what do I know?
    Now I have to make brick without straw for several specialty providers who may have to make employment cuts and add to the unemployment numbers just to keep going. What message is being sent to our nations physicians? There is and has been some abuse out there that’s true but alot of good doctors are going to suffer for the bad ones. Let’s hope they all don’t just quit.

  21. Tia, CPC says:

    The modifier “AI” is the modifier the admitting physician will need to add to the initial inpatient hospital or nursing facility visit they will be billing. This modifier is to distinguish his / her service as the admitting service, and to distingush his status from that of any “consultants” also reporting initial care codes for the patient.

    Potential problems: What if the admitting physician forgets to append modifier AI to their claim?
    What documentation will be reqiured to support multiple initial service claims ie: consults? What if more than 1 “consult” is requested by the admitting Dr during the same hospital stay, and the same E/M code and diagnosis code are used by the admitting Dr and the “consult” Dr? Consultation documentation requirements disappear along with the consultation codes for Medicare purposes.

    My advise is to bill out your doctors charges as soon as you can, if your claim gets in first you’ll probably get paid, and if the admitting doctor forgets to use the modifier or doesn’t submit their claim within a few weeks, their claim may get denied, and have to be corrected and resubmitted. Education to the PCP staff will be needed, so they are aware they now have additional coding requirements, so the PCP and the specialists get paid.

  22. DEE says:

    I just figured out that the potential loss for our doctors is between $53.52 and $66.18 per consult. We always tried to follow the rules. We never billed a consult unless we had a written request with the word “Consult” on the referral. It is a shame that everyone has to pay for those that billed inappropriately. CMS could have made a form that had to be used by the referring physican that listed the intent of the referring physician (consult or transfer of care) and insisted that it had to be used to bill a consult, or they could have adjusted the fees on the consults, but not recognizing the extra work that a specialist performs is ridiculous!! Healthcare was one one of the few places that people could get jobs in the US. I guess that is gone now!!

  23. Tia, CPC says:

    see type in at search : MLN Matters Article #6740 just release this afternoon, may answer some of your questions.

  24. dsagers says:

    The abuse of these codes are what prompted this. How long has CMS tried to get providers and staff to understand and correctly bill consult codes? It’s been my experience when providing education on consult guidelines, most providers would spend sooooo much time trying to figure out a way to get AROUND the guidelines by using specific wording in their notes or trying to get requesting offices to do things a certain way to support the consult code, it was craziness. If you remember the OIG report on consult services that was released in 2006, 75% of the consults reviewed did not support a consult code. What else can CMS do? I hate this latest development for the ones who truly did make a conscious effort to bill according to service type (instead of reimbursement amount) but unfortunately, majority is going to rule this one….If you abuse it, eventually, you’re going to lose it.

  25. Jeff says:

    Removing the consult removes the communication back to the referring doctor. No more letters, no more updates, no more preop clearances, no more back-and-forth coordination of care. We will simply give the patient a copy of their chart note, however legible, and let the patient hand carry it to those doctors interested in the finding; hopefully they can read our writing. With no reimbursement for the typist, stamp/envelope, or mailing effort, we’ll save money on dictation and pulling charts for proofreading.

    Primary care will suffer more on their incomes from lost revenue doing preop clearances and responding to specialist requests for evaluations, no longer reimbursed at the Consult level. Specialists will do fine just by limiting their services outside the office, and even doing more primary care tasks that would have come back to the internists.

  26. Louise says:

    I have a few concerns about these CMS changes.
    1. How will this impact reimbursement if the payer is reimbursing off of last years RVus?
    2. Does this have any affect on CCI edits?
    3. What about crossover Medicare claims or COB when Medicare is involved?
    $ I forsee upcoding being done to compensate the difference in payment levels.

  27. Christina says:

    Most of the major carriers (aside of Medicare) in our area DO NOT plan to follow Medicare Consult guidelines at this time. That’s not to say they will not follow suit at a later time, but for now, they are not! A decision will have to be made whether we are going to choose to follow Medicare guidelines across the board, or for now, continue to charge Consult codes to those carriers still reimbursing. Kind of hard to turn your back on the $$ from carriers not following Medicare. Of course, the Medicare Advantage plans must follow Medicare guidelines, contrary to what other people who call themselves “experts” in this area, are telling everyone!

  28. Marilyn says:

    After reading the recent explanation from Medicare, I believe that the decision will affect reimbursement more drastically across the industry than may be expected. First….a couple of observations. In inpatient billing by consultants….there should be different diagnoses for their services so that will help to differentiate between providers using the same CPT level code. Second, being able to bill Medicare as secondary coverage is going to be the driving force for choice of CPT code. Because everyone may have to use “standard” E&M codes for billing the primary insurances in order for Medicare to pay as secondary, the reimbursement will fall considerably from regular insurances who, too, historically have paid more for consult codes. That means you could get substantially less for the same level of service as must be provded in a consult or do a lesser service than a consult and bill accordingly. If you contine to bill consult codes to regular insurances – then the claim must be recoded to submit to Medicare for secondary payment – what a hassle! For specialists who do a high volume of consults, their reimbursement may be seriously impacted unless they stop providing services to Medicare participants which may negatively impact the quality of care our elderly patients may receive. Do you suppose CMS thought about that as a “cost-saving” option for bugetary purposes? i.e. fewer services provided to their participants on the whole – or fewer doctors who will continue to see Medicare participants (THEY CAN JUST QUIT PROVIDING SERVICES TO MEDICARE PATIENTS!)

  29. Karen Wolmer says:

    This new ruling will cause a major financial impact on specialists. I believe that commercial carriers will soon follow. So, where do we go from here, if the Office of Inspector General would have investigated complaints made to them regarding fraud against physicians illegally charging for consults, this would have never happened! Special thanks to all the physicians committing fraud and advise them that sooner or later you will be found out! To those physicians practicing by the book, I feel sorry for you, you are the ones being penalized by your peers.

  30. dsagers says:

    CMS has stated in the MLN that “Consulting” providers should still continue to communicate the results of the evaluation back to the requesting physician…….

  31. Amy says:

    Does anyone have a copy of a crosswalk publsihed by, I believe, CMS. I saw one reference to it in one of the previous comments but I would like to get back to the original publication.

  32. Richene says:

    Instead of eliminating the consult codes that describe the service rendered, why didn’t CMS just reduce the RVU for these consult codes to the amount paid for similar services as they are now telling us to code. Example: IP consult code 99253 would match criteria for 99221, 99254-99222 and 99255-99223. Codes 99251 and 99252 could be assigned RVU’s for subs visit codes 99231 and 99232 with elements for those services being documented. OP consult reimbursement could be determined on new patient RVU’s (99201-99205). This would allow the intent of the service to be coded but reduce the amounts since that is what this seems to be all about anyway with CMS. And all payers would recognize these codes versus the mess we have now of some accepting consult codes and some denying them.

  33. Debbie says:

    Summa has already announced following suite with Medicare.

  34. Natalia says:

    In Ohio the MCD (Medicaid plan) and Wellcare have decided to follow CMS and do away with the consult code as of 04/01/2010.

  35. jessie says:

    Does anyone have a list of commercial insurance companies that are still accepting consult codes and one that are following medicare guidelines? I am looking for information that the insurance companies have put on there web sites.

  36. Antony Clement says:

    What is the procedure to bill the consult code to Medicare as secondary if primary payer accepts and pay consultation code?

  37. arun says:

    Need office visit consult code

  38. arun says:


  39. arun says:

    may sala

  40. MARY HALL says:

    my question is how do we bill a v code for a family planning consult ? or a vasectomy elvauation.

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