CMS Provides Reporting Consultative Services Details

Heated coding discussions seek resolution to unanswered questions.

By Karen Pettit, BBA, CPC, CMC, and G. John Verhovshek, MA, CPC

As you are probably well aware, the Centers for Medicare & Medicaid Services (CMS) no longer recognizes CPT® consultation codes 99241-99245 (outpatient) and 99251-99255 (inpatient), effective Jan. 1. This policy change was discussed in January’s Coding Edge article, “Brace Yourself for Change: CMS Says No More Consults,” pages 46-48, and it has been heatedly discussed within coding circles for months. The 2010 Medicare Physician Fee Schedule (MPFS) Final Rule, published Nov. 25, 2009 in the Federal Register (, finalized the decision, but left many unanswered questions as to how providers were to report consultative services provided to Medicare patients.

Evaluation and Management – CEMC

Since then, CMS has released Change Request (CR) 6740 ( and Medlearn Matters article MM6740 Revised ( to provide some answers.

Modifier AI Will Serve as Expected

For the hospital inpatient setting, CMS instructs providers performing services that previously would have been coded with 99251-99255, to instead report initial hospital care codes 99221-99223. Similarly, CMS instructs skilled nursing facilities (SNFs) to report consultative services to Medicare payers using 99304-99306.

Based on this, admitting physicians would report 99221-99223 and 99304-99306 for the admission itself, but so would any physician providing initial consultative services for the same patient. “As a result,” CR6740 notes, “multiple billings of initial hospital and nursing home visit codes could occur even in a single day.”

This sort of thing would naturally be flagged; to prevent a claim from being denied, the admitting or attending physician who oversees the patient’s care should append new-for-2010 HCPCS Level II modifier AI Principal physician of record to the initial visit code. This will distinguish the service from those of any other physician’s who may furnish specialty (consultative) care.

“All other physicians and qualified non-physician practitioners who perform an initial evaluation on this patient shall bill only the E/M [evaluation and management] code for the complexity level performed,” CR6740 instructs.

To report subsequent services (whether consultative or not) for the same patient during the same inpatient stay, use the appropriate subsequent care codes (e.g., 99231-99233 for hospitals or 99307-99310 for SNFs).

For example: A patient presents to the emergency department (ED) with chest pain. The ED physician evaluates the patient and submits a code from the ED visit codes 99281-99285 based on the service level performed and documented.

The ED provider calls a cardiologist to get his opinion on the patient. The cardiologist comes to the ED, evaluates the patient, and decides to admit the patient. The cardiologist admitting the patient would select a code from the initial hospital visits (99221-99223), reflecting the complexity of the work performed and documented. Modifier AI would be appended to the cardiologist’s service to indicate the patient is being admitted to his service and that he will be overseeing the patient’s care.

If other evaluations from other specialties are needed during the admission, the specialty providers also would submit an initial hospital visit to reflect the service level they performed and documented. For instance, if the patient also has uncontrolled diabetes and the cardiologist requests the patient be evaluated by an endocrinologist, the endocrinologist would select a code for the initial hospital visit series (99221-992233) reflecting the service she performs. Modifier AI is not necessary for the endocrinologist’s service because she is not overseeing the patient’s care and is not the admitting physician.

Note: Medicare expects ED visit codes (99281-99285) to be used by providers furnishing consultative services in the ED when the consulting provider is not admitting the patient. In our example, if the cardiologist had elected not to admit the patient, he would report an ED visit code to reflect the consultative service performed.

Document Patient Care, Medical Necessity

Documentation guidelines meant to define the services described by consultation codes also were eliminated. This left providers questioning whether specific documentation requirements would be mandated to substantiate consultative services billed using hospital inpatient, SNF, office, or outpatient visit codes.

MM6740 Revised states:

“Conventional medical practice is that physicians making a referral and physicians accepting a referral would document the request to provide an evaluation for the patient. In order to promote proper coordination of care, these physicians should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting physician. This is not to be confused with the specific documentation requirements that previously applied to the use of the consultation codes.”

Dr. Paul Deutsch, medical director for Jurisdiction 13 Medicare Administrative Contractor (MAC), expressed during a Dec. 16, 2009 ACT Teleconference that it would be in the provider’s “best interest” to continue to document a request and report.

Taken together, these statements might be translated as “although there are no longer formal requirements to document a consultation request, or for the consulting provider to communicate his or her recommendations to the requesting provider, CMS nevertheless will expect to find these items documented because they are necessary for proper patient care.”

Providers should focus on the issue of medical necessity, while documenting the basic elements of a consultative service as defined by CPT® (a request, an evaluation made, and recommendations returned to the requesting physician)—both to ensure continuity of patient care and to establish the services as medically justifiable and separate from those services furnished by other providers.

Approach Service Gap with Caution

As noted in January Coding Edge article, “level of service” requirements for initial inpatient services and inpatient consultation services are not equivalent. For example, a level one consultation under CPT® guidelines requires a problem-focused history, problem-focused exam, and straightforward medical decision making (MDM). A level one initial inpatient visit requires a (more extensive) detailed or comprehensive history, detailed or comprehensive exam, and straightforward or low MDM. This creates a service gap below the lowest-level initial inpatient code for those physicians evaluating a patient to provide opinion or advice to another physician.

CR6740 instructs, “All E/M services shall follow the [familiar 1995 or 1997] E/M documentation guidelines,” while MM6740 Revised asserts, “In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.”

The question is: If documentation must still meet code requirements, whether coding is based on key components or based on time (where counseling/coordination of care dominates the service, time may be considered the controlling factor for coding if all requirements are met), how do we code services that fall within the gap?

CR6740 states that E/M codes should be selected based on, “where the visit occurs and that identify the complexity of the visit performed.” Because the complexity of an E/M visit generally is reflected by the documentation of the key components, this appears to reinforce that services must meet code requirements. This also is referenced in CR6740: “Select the code based upon the content of the service.”

So, if a specialist performs an inpatient evaluation and documents a problem-focused history and exam and MDM of straightforward complexity (previously billed as a 99251), what are the options?

Because the documented key components would not meet the requirements for the lowest level initial hospital visit, it seems that we are left with only the level one subsequent hospital visit (99231). Code 99231 also requires a problem-focused history and exam and MDM of straightforward complexity—and as such, it seems to satisfy the new directive received from Medicare (even though only two of the three key components are required for subsequent hospital visits).

This question was addressed in several teleconferences provided by National Government Services (NGS), MAC for Jurisdiction 13. NGS confirmed on Jan. 6 during the Medicare Part B Consultation Coding Changes teleconference to use subsequent hospital visit codes (99231-99233) when the documentation/complexity of the visit does not meet the coding requirements for initial hospital visit codes. If you reside in another jurisdiction, you may want to pursue this with your own local contractor/carrier to ensure you are in line with what they will require.

There is one exception to this requirement, as noted in CR6740. If a physician performs and documents a level five established patient office visit (99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family (which requires a comprehensive history and/or exam, MDM of high complexity) a few days prior to the admission and documents less than a comprehensive history and exam on the date of admission, the physician may bill 99215 for the office visit (performed previously) and 99221 Initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit for the hospital admission.

CR6740 and MM6740 Revised reiterate and stress proper use of face-to-face prolonged service codes (99354/+99355) with office/outpatient settings and home services codes. For more on prolonged service codes, and time-based E/M coding in general, see the February Coding Edge article “Go Beyond the Basics of Time-Based E/M Coding” (pages 44-46).

MSP Issues Gain Clarity

CMS deserves credit for clarifying issues related to Medicare secondary payments (MSP), as outlined on pages 5-6 of MM6740 Revised. Specifically:

“In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and others billing for these services may either:

  • Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or
  • Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

Note: The first option may be easier from a billing and claims processing perspective.

For more on this topic, see the February Coding Edge, “Consults Continued …” (Letters to the Editor, page 6).

The bottom line: CMS has taken steps to help providers and payers adjust to life after consults, but substantial issues remain unresolved. For now, we recommend documenting consultation services as stringently as you always have, while following to the letter CMS coding instructions for Medicare payers. It is also a good idea to check with your local contractor/carrier for additional guidance. Their websites can be a great resource, and provide information on teleconferences and trainings that are available, as well as answers to frequently asked questions (FAQs). Talk to your private payers to see how they’ll handle consultation services going forward. Time may bring further changes and clarification; be aware and prepared to act when the time comes.


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