Check Payer Policies for Consult Code Coverage

Jan. 1 has come and gone and so, too, have CPT® consultation codes (99241-99255). As predicted, Medicare Administrative Contractors (MACs) and other payers have implemented this policy change brought forth by the Centers for Medicare & Medicaid Services (CMS). It’s important to note, however, that this change in coverage applies to public health plan options only. Many commercial plans continue to reimburse for consultation services.
UnitedHealthcare, for example, recently communicated to members that it has implemented the CMS regulations for its UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, but says it will continue to reimburse commercial plans for CPT® codes 99241-99245 and 99251-99255 at this time.
AmeriChoice Medicaid plans that follow Medicare rules for their fee schedules have also implemented CMS rules. For all other Medicaid states, however, AmeriChoice currently follows the UnitedHealthcare commercial position and “will continue to pay for consult codes until directed otherwise by a state to pursue other strategies.”
Other carriers are following suit. To prepare your practice for issues that may ensue due to the most recent evaluation and management (E/M) coding changes, read “Ask 3 Questions to Head Off 2010 Consult Problems.” For current CMS instructions pertaining to consult codes, refer to MLN Matters revised article MM6740.

Why the Change?

If you’re wondering why CMS initiated the change in policy in the first place, you may want to read the article “Is it Time to Eliminate Consultation Codes?” in the Archives of Internal Medicine. According to the author, Joel I. Shalowitz, MD, MBA, “Consultation codes are being billed erroneously at a high rate. Furthermore, the differential cost to Medicare of these codes over those for new patient evaluation and management codes is over half a billion dollars per year.”

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18 Responses to “Check Payer Policies for Consult Code Coverage”

  1. kathy kimpler says:

    consult codes have changed to other E&M codes

  2. Carol F Foutch, CPC says:

    I just heard yesterday that CMS may be reconsidering on the Consult codes.

  3. Chastity Cecil-Nault, CPC says:

    Carol-Where did you here that CMS may be reconsidering?


    I wonder if our doctors will ever get back to being able to practice medicine and not insurance OR law?

  5. Margaret Nahmias says:

    Why not just make the rules clearer before getting rid of them altogether?

  6. Sarah Biegler says:

    I’m particularly pleased with the fact that we had so much notice when they finally decided to go ahead and do it; issues galore.

  7. Eve Harris says:

    Although I am only just starting out in the coding field, I know one thing well from working in D.C. a few years ago: once the Feds get hold of something, they fix it even if it is not broken! It makes for bigger bureaucracy and more Indian Chiefs! Yes, I agree; making the rules clearer and getting rid of some of those acronyns would be a good start for sure.

  8. theresa dix says:

    it’s pretty confusing.

  9. Dana Freycenet says:

    Fasten your seatbelts. More government bureaucracy yet to come!

  10. Sharon says:

    I agree with all of the comments made but look at hte bright side. It’s also job security. LOL

  11. darlene says:

    what is the best way to check how this change affects the HMO plans?

  12. Lisa says:

    What other insurance companies that you know of is following the medicare changes as well???

  13. roy says:

    They published this in July 2008 and all societies were aware of the change coming. 75% of consult are inappropriate, I guess this was doctor’s own doing.

  14. Karen says:

    Oh well…I guess all these changes are good for our brains! Helps ward off Alzheimers..right? If only we had more hours in a day to keep up with the publications.

  15. 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.

  16. Deanna says:

    I am teaching ICBS and my students are asking me what to bill in place of the consult codes. I don’t have an answer to give them because I am getting a lot of conflicting info. Where do I go for the definitive answer ?

  17. Jennifer 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.

  18. ELIZABETH COOK says:

    Hello I was wondering by chance do either one of you have a list of carriers that are not excepting the consult codes other than Medicare and Medicaid? Thanks for your help