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Thread: New Consult guidelines for MC Advantage & Medicaid

  1. #1
    Join Date
    Apr 2007
    Green Bay Wisconsin

    Question New Consult guidelines for MC Advantage & Medicaid

    AAPC: Back to School
    I have reviewed the CMS Transmittal 1875 & the MLN Matters 6740 and understand what they are telling us for Medicare patients. My question is how are the Medicare Advantage plans handling coverage for consults? I read in the MLN Matters #6740 that this article is only for physicians billing the Medicare fee for service program it does not apply to Medicare Advantage or non Medicare insurers however I have called our BC/BS Smart Value and they told me they will be following the Medicare guidelines. I have not been able to get an answer from Humana Gold yet as to how they will handle consults. Those are the two larges Medicare Advantage plans in our area for 2010. I'm also wondering if Medicaid is planning on following CMS Medicare's guidelines. We are located in Wisconsin. Does anyone else know what the Medicare Advantage plans or Medicaid are going to do?

  2. #2
    Join Date
    Apr 2007
    Greeley, Colorado


    We don't participate with Medicare replacement plans, but I do know that our state Medicaid (CO) is not following Medicare regarding consults. Contact your state Medical Society to see if they have answers to these questions for you.
    Happy New Year!
    Lisa Bledsoe, CPC, CPMA

  3. #3


    I have been reading up on this particular discussion. I am in in Illinois and our Medicare contractor is WPS. I was told and have it in writing that the medicaid plans will not be participating in the no consult decision. I also spoke with and have in writing that BCBS PPO of Illinois will not be participating and I believe Health Alliance HMO will not as well. I am still waiting for a response from Humana Gold CHoice and others to find out what they will be doing, but I have heard that they will not be following, but as you know you cannot believe everything you hear. I am going to make sure I have it in writing on their letterhead to make sure. When I do get a response I will post the reply they have given me. I hope this helps.

    Jennifer C., CPC, CIMC

  4. #4
    Join Date
    Apr 2007
    Kansas City, MO


    So far every MA plan I have spoken with is following the Medicare guidelines, including Humana Gold. I did hear from one, Coventry Advantra (may not be in your area) that they will pay for consults until 3-31-09, since that is the date they redo their contracts. Our state medicaid (Missouri) is NOT following the new CMS rule.

  5. #5
    Join Date
    Apr 2007
    Kansas City, MO


    Based on the information we have received, UHC Medicare Advantage and Humana Medicare Advantage are following CMS and will not be accepting consult codes. This information can be found on their web sites. Kansas Medicaid is still looking into the issue, no definite decision has been made.
    Angela Jordan, CPC
    AAPC of Kansas City
    National Advisory Board Representative Region 5

    Medical Revenue $olutions
    Senior Managing Consultant


  6. #6
    Join Date
    Apr 2007
    Milwaukee WI

    Default As of now

    As of now (Wed Jan 6, 2010), Wisconsin Medicaid is still accepting the consultation codes.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Join Date
    Apr 2007
    North Carolina


    I just visited our UHC site....

    For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

    For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

    For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective January 1, 2010. For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed by each state to pursue other strategies.


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