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 erroneouslyat a high rate. Furthermore, the differential cost to Medicareof these codes over those for new patient evaluation and managementcodes is over half a billion dollars per year.”
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