Wiki Consult codes

[KaylaRieken]

After Medicare said they wouldn’t pay for consult codes, our office stopped billing them for all insurances. Now our providers are wanting to code consult codes when seen in the office. Does anyone do this? What has to be documented? What insurances do. It pay for it? Any advice would be greatly appreciated.

 

[Orthocoderpgu]

After Medicare said they wouldn’t pay for consult codes, our office stopped billing them for all insurances. Now our providers are wanting to code consult codes when seen in the office. Does anyone do this? What has to be documented? What insurances do. It pay for it? Any advice would be greatly appreciated.

Question: Are the three requirements for a "Consultation" being met? Most major insurance companies has followed the lead of CMS and won't pay for any consultation code, so why would your provider/s want to submit a code that they pretty much know is not going to be paid?

 

[csperoni]

Once Medicare did away with consult codes, we continued to bill for commercial insurance (assuming a medical coding definition of consult was done as pointed out by @Orthocoderpgu). As each insurance updated their policy to no longer accept consult codes, we were billing them fewer and fewer.
Particularly with the 2021 outpatient E/M guideline changes, my personal opinion is that since hardly any commercial carriers still accept, and it's harder to use 2 sets of coding leveling guidelines, it is just simpler to no longer use consult codes at all. Assuming you meet the coding definition of consult, if 98% of your consult codes get denied, that does not seem like a great way to get paid.
Don't forget since consults still use the 95/97 guidelines, you may frequently get a higher level with 99202-99215 if your clinician misses an exam bullet point or doesn't completely document a history.

 

[amyjph]

Agree with the advice above. However, some Work Comp carriers do pay them. In my past experience in some practices we knew which payers would still pay consult codes and used them sparingly. Many of our providers knew the requirements and documented well. I will say it was mostly for hospital visits where a specialty consult was called, rarely in office. As Christine states above with the new guidelines it's harder to meet in office.

 

[jkyles]

Just FYI, Aetna ended coverage of office consults effective today. I think that's the last of the major payers to cut coverage.

Also, in 2023 the CPT manual will be updated to delete 99241 and 99251 and make additional revisions to the remaining consult codes. https://www.ama-assn.org/system/files/2021-03/february-2021-summary-panel-actions.pdf So if your providers do start reporting them again they should know that the rules will likely change in a few months.