Wiki Consultations, payers and new guidelines

[trarut]

Hello everyone. How are you handling office consultations these days? Many payers don't accept the 9924x codes and require new patient codes to be used instead. Are your physicians documenting consults using 95/97 guidelines or the 2021 guidelines in case the payer uses 9920x codes? TIA!

Disregard. I've worded my question poorly and will come back to edit after giving it some thought. Thanks to those of you who tried to answer. Sorry I led you down the wrong path

 

[Orthocoderpgu]

Consultations are not part of the DG. The reason why Medicare and now most payers don't pay for "consultation" codes is that there were not being used correctly. My question to you is are you meeting all three requirements of a consultation? Chances are your dealing with Dr. A wants the patient to be evaluated by Dr. B, and Dr. B wants to bill a consultation which is incorrect. If you are meeting all three requirements of a consultation, you will need to keep track of which payers still consider them for benefits and only use them when that is the insurance being billed.

 

[csperoni]

So few payors still recognize consult codes that we don't even bother trying to use them anymore. We just use 9920x for all payors.

 

[trarut]

Consultations are not part of the DG. The reason why Medicare and now most payers don't pay for "consultation" codes is that there were not being used correctly. My question to you is are you meeting all three requirements of a consultation? Chances are your dealing with Dr. A wants the patient to be evaluated by Dr. B, and Dr. B wants to bill a consultation which is incorrect. If you are meeting all three requirements of a consultation, you will need to keep track of which payers still consider them for benefits and only use them when that is the insurance being billed.

Thank you for your response and I am aware of all that. Yes, we do meet the requirement for a consultation when we bill them and we do keep track of which payers are accepting consults and which ones do not.

I've tried multiple times to clarify what I'm trying to ask and it's not working so I'll have to revisit this topic at another time.

 

[trarut]

So few payors still recognize consult codes that we don't even bother trying to use them anymore. We just use 9920x for all payors.

Thanks for this input. I wish our providers would do the same but they aren't there yet.

 

[csperoni]

Thank you for your response and I am aware of all that. Yes, we do meet the requirement for a consultation when we bill them and we do keep track of which payers are accepting consults and which ones do not.

I've tried multiple times to clarify what I'm trying to ask and it's not working so I'll have to revisit this topic at another time.

If your question is whether when billing consult, you level based on hx, exam and MDM (or time if >50% in counseling/coordination of care), the answer is yes.
If you are billing 99202-99205 or 99211-99215, you level based on MDM or total clinician time.
In my opinion, the clinician should simply be performing what they believe is medically necessary and then it is coded according to the documentation. There is no crosswalk from consult to new since 99244 is NOT the same as 99204; not even the same elements anymore. The clinicians should not be documenting differently based on the carrier.
If this was not what you are asking, perhaps you could clarify.

 

[trarut]

If your question is whether when billing consult, you level based on hx, exam and MDM (or time if >50% in counseling/coordination of care), the answer is yes.
If you are billing 99202-99205 or 99211-99215, you level based on MDM or total clinician time.
In my opinion, the clinician should simply be performing what they believe is medically necessary and then it is coded according to the documentation. There is no crosswalk from consult to new since 99244 is NOT the same as 99204; not even the same elements anymore. The clinicians should not be documenting differently based on the carrier.
If this was not what you are asking, perhaps you could clarify.

That's not what I was asking but I appreciate the response. In regards to the bolded, I have always instructed providers to document the service performed and would not dream of telling them otherwise. It's my team's job to worry about the payer rules around those services; the provider needs to focus on the patient not what insurance they have.

I feel the new guidelines leave some gray area when we have a consult documented, a payer that won't accept consult codes, levels that no longer match and, if time-based, time rules that differ. So I'll revisit this when I can rephrase my question.

 

[shanamarie]

Hello everyone. How are you handling office consultations these days? Many payers don't accept the 9924x codes and require new patient codes to be used instead. Are your physicians documenting consults using 95/97 guidelines or the 2021 guidelines in case the payer uses 9920x codes? TIA!

Disregard. I've worded my question poorly and will come back to edit after giving it some thought. Thanks to those of you who tried to answer. Sorry I led you down the wrong path

We have a similar situation in our clinic. I have advised that if a consult is requested then use the old guidelines 95/97. Our physicians bill their own services so they needed to know when to follow the old guidelines, and when to follow the new guidelines. Otherwise they would have no idea what to bill. If our billing system catches a charge that can’t be billed as a consult due to insurance, then we review based on 2021 guidelines for new/est patient. Typically we have to review based on MDM because time wouldn’t be documented for the consult. I hope this helps!

 

[trarut]

We have a similar situation in our clinic. I have advised that if a consult is requested then use the old guidelines 95/97. Our physicians bill their own services so they needed to know when to follow the old guidelines, and when to follow the new guidelines. Otherwise they would have no idea what to bill. If our billing system catches a charge that can’t be billed as a consult due to insurance, then we review based on 2021 guidelines for new/est patient. Typically we have to review based on MDM because time wouldn’t be documented for the consult. I hope this helps!

That does help, thank you!

 

[KoBee]

What about if a provider doesn't meet the 3R's for those payers who do accept the consult codes, do you use CPT 99202-99205?

 

[csperoni]

What about if a provider doesn't meet the 3R's for those payers who do accept the consult codes, do you use CPT 99202-99205?

Yes, if your "consult" does not meet the coding definition of consult, you bill an E/M 99211-99205 office; 99221-99233 inpatient. That same rule applied even when all carriers recognized consult codes. The overuse/abuse findings by CMS is what lead to the discontinuation.

 

[KoBee]

Yes, if your "consult" does not meet the coding definition of consult, you bill an E/M 99211-99205 office; 99221-99233 inpatient. That same rule applied even when all carriers recognized consult codes. The overuse/abuse findings by CMS is what lead to the discontinuation.

thank you for the quick prompt response, do you know where i can find this source so i can send it to providers?

 

[csperoni]

thank you for the quick prompt response, do you know where i can find this source so i can send it to providers?

I believe it's in the CPT definitions, but I do not have my books with me. If you don't meet the definition of any service, you can't bill for it.
Here's an AHIMA article about it, although anything referencing 1995 or 1997 guidelines for outpatient should say 2021's guideline for MDM only.
AAPC article. E&M University guidance. OIG findings.
Honestly, if you google it, there will be 100s of articles. The ones above were all just on the first page.

 

[KoBee]

I believe it's in the CPT definitions, but I do not have my books with me. If you don't meet the definition of any service, you can't bill for it.
Here's an AHIMA article about it, although anything referencing 1995 or 1997 guidelines for outpatient should say 2021's guideline for MDM only.
AAPC article. E&M University guidance. OIG findings.
Honestly, if you google it, there will be 100s of articles. The ones above were all just on the first page.

Thank you , I'm just having trouble to distinguish or should i say what to specifically look for to validate the 3rs. Majority of providers but in a referral and then the consulting provider will document in his report who the patient is being referred by. But then everything else looks like a general office visit of HPI/EXAM/MDM. I don't see or can't tell if what i am seeing what qualifies as a rendering an opinion and written report.

I thought if the consulting provider just does a report then that counts as a written report. I don't see where most of our provider document an " opinion " back to the primary. To what exactly should the consulting provider be documenting to consider and opinion? I think that is where i get myself confused :/

 

[thomas7331]

Thank you , I'm just having trouble to distinguish or should i say what to specifically look for to validate the 3rs. Majority of providers but in a referral and then the consulting provider will document in his report who the patient is being referred by. But then everything else looks like a general office visit of HPI/EXAM/MDM. I don't see or can't tell if what i am seeing what qualifies as a rendering an opinion and written report.

I thought if the consulting provider just does a report then that counts as a written report. I don't see where most of our provider document an " opinion " back to the primary. To what exactly should the consulting provider be documenting to consider and opinion? I think that is where i get myself confused :/

There does have to be a record of the opinion being sent back, unless the two providers share the same medical record. So a copy of the 'opinion' letter needs to be kept in the chart if the provider who requested the consultation is from an outside practice.

But one thing to keep in mind: a referral is not a consultation. A consultation is a specific request for an opinion from a specialist. When a provider requests a consultation, they are asking for another provider's input - they want that provider's opinion in order to assist them in diagnosing the patient and/or creating their own treatment plan. It's different from a referral which is simply sending the patient to the specialist. I've found it helpful to explain it to providers this way - they shouldn't be consider a visit a consultation just because a patient was referred to their practice.

If the patient is just being told, for example, 'you should see a dermatologist about this, here is the name of one I recommend' - that is just a referral. But the the provider is sending the patient because that provider needs to work together with the specialist , for example a surgeon is planning a procedure and the patient has a heart condition that could be affected by the surgery, the surgeon may need the cardiologist's opinion on the risks or the right way to manage the heart medications before and after surgery - then that may qualify as a consultation.

 

[Patricia P Williams]

Anyone else who still uses Consultation Codes (99241-99245) seeing denials for these now from Anthem and Anthem Healthkeepers? Beginning with Date of service 10/01/2021, all of ours are being denied now. However, I cannot find a policy update from Anthem regarding this.

 

[xynthz_28]

There does have to be a record of the opinion being sent back, unless the two providers share the same medical record. So a copy of the 'opinion' letter needs to be kept in the chart if the provider who requested the consultation is from an outside practice.

But one thing to keep in mind: a referral is not a consultation. A consultation is a specific request for an opinion from a specialist. When a provider requests a consultation, they are asking for another provider's input - they want that provider's opinion in order to assist them in diagnosing the patient and/or creating their own treatment plan. It's different from a referral which is simply sending the patient to the specialist. I've found it helpful to explain it to providers this way - they shouldn't be consider a visit a consultation just because a patient was referred to their practice.

If the patient is just being told, for example, 'you should see a dermatologist about this, here is the name of one I recommend' - that is just a referral. But the the provider is sending the patient because that provider needs to work together with the specialist , for example a surgeon is planning a procedure and the patient has a heart condition that could be affected by the surgery, the surgeon may need the cardiologist's opinion on the risks or the right way to manage the heart medications before and after surgery - then that may qualify as a consultation.

I have a follow-up question about referral. How about if the PCP refers a patient admitted in the SNF facility to a Pulmonologist and the Pulmo visits the patient in the SNF, would the CPT be coming from 9920x office visits or 9930x SNFs visits? Most payers don't pay for consult codes so I am torn between those 2 locations. The Pulmo by the way is not employed in the SNF, he is basically just going to the facility because of PCP referrals.

 

[mjbcpc]

Anyone else who still uses Consultation Codes (99241-99245) seeing denials for these now from Anthem and Anthem Healthkeepers? Beginning with Date of service 10/01/2021, all of ours are being denied now. However, I cannot find a policy update from Anthem regarding this.

With the exception of Colorado, Anthem is no longer paying for consult codes effective 10/1/21. I just found this out today. Here is the link https://www.anthem.com/docs/public/inline/C-09010.pdf