CMS Clarifies Consult Code Reporting

Since announcing that CPT® consultation codes (ranges 99241-99245 and 99251-99255) would no longer be recognized for Medicare Part B payment effective Jan. 1, the Centers for Medicare & Medicaid Services (CMS) has been bombarded with questions.

In response, the agency has issued MLN Matters Special Edition article SE1010, entitled “Questions and Answers on Reporting Physician Consultation Services.” MLN Matters article MM6740 was also revised Feb. 24 to clarify some language and add reference to SE1010.

Evaluation and Management – CEMC

CMS answers a number of questions in SE1010, such as:

Q: Is CMS going to crosswalk the CPT consultation codes that are no longer recognized to the E/M codes for each setting in which an E/M service that could be described by a CPT consultation code can be furnished?

A: “No,” replies CMS, “providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide ….”


Q: Will Medicare contractors accept the CPT consultation codes when Medicare is the secondary payer?

A: “Medicare will also no longer recognize the CPT consultation codes for purposes of determining Medicare secondary payments (MSP).”

CMS further explains that if the primary payer continues to recognize CPT® consult codes, providers may bill the primary payer either an evaluation and managment (E/M) or consultation code, and then report the amount actually paid by the primary payer, along with the same E/M code or an E/M code that is appropriate for the service, to Medicare for payment determination.

That’s great but in some cases, Medical Office Billing & Collections Alert warns, “the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department. You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.”

And if your physician’s documentation doesn’t reach the lowest initial hospital care code (99221), which requires a detailed history and detailed exam, what then?

“Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

Other Medicare administrative contractors (MACs), however, have instructed practices to use the Not Otherwise Classified (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Best Advice: “Check with your contractor,” Buechner advises.

Read the Medical Office Billing & Collections Alert article for more good advice. See also SE1010 for more CMS guidance relating to consult code changes for 2010 Medicare reporting.


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3 Responses to “CMS Clarifies Consult Code Reporting”

  1. Wendy Rowe, CPC says:

    Would we use a subsequent inpatient visit (99231-99232) as appropriate when the detailed HPI or detailed exam for a Medicare Patient in place of a Consult?

  2. Keith says:

    This is what happens whe you have a President who STILL hasn’t decided on who should be running CMS…You have an Acting Admin. and the agency just runs wild.

  3. Susan says:

    Please stick to the facts, not your opinions and keep your political views to yourself.

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