Track Consultation Code Reimbursement Policies
Question: Providers in my office sometimes perform consultations. We bill these with CPT® codes 99242-99244 but only receive payment sometimes. Am I doing something wrong by using these codes? Pennsylvania Subscriber Answer: The Centers for Medicare & Medicaid Services (CMS) stopped providing reimbursement for codes 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) to 99244 (… moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) in 2010, but not all commercial carriers followed suit. You need to check with each individual payer to see whether they reimburse for consultation services reported with 99242-99244. Some payers have guidance on how to report the services and be paid. For example, Independence, an independent licensee of Blue Cross Blue Shield, says, “when providers see Independence Medicare Advantage HMO and PPO members, providers need to code patient evaluation and management (E&M) codes that represent where the visit occurred and identify the complexity of the visit performed.” As each payer may have a different rule, you may save yourself some time and headaches by creating a spreadsheet that details which payer accepts these consultation codes and which payer prefers reporting of the services with other E/M codes. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
