Coding Articles


Some payers accept consult codes - but be sure that's what you did

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Question: For new patients who are not on Medicare, our office uses the office consultation codes 99241-99245 if referred by a doctor and 99201-99205 if self-referred. The E/M criteria are met for time, history and exam for all codes. Is our use of the consultation codes correct? Is it commercial carrier dependent?

Answer: We don't talk much about the outpatient consultation codes 99241-99245 since Medicare stopped paying then in 2010 - though some providers continue, futilely, to bill them. Medicare dropped these codes because "they were thought to be widely abused - or maybe it would be better to say, they were misused because of misunderstanding about their purpose," says Stuart Newsome, vice president for business development at Alpha II LLC in Montgomery, Ala., and author of Medical Decision Making in E/M Coding. But CMS includes 99241-99245 (and the inpatient versions, 99251-99255) in its fee schedule and their rates compare favorably with outpatient E/M codes: Level 3 outpatient E/M for a new patient pays $109.80 (national non-facility par) and $74.16 for an established patient, while the level 3 outpatient consultation code is valued at $124.20, and many private payers still accept these codes. Why does CMS set fees for service they don't offer? Because many non-Medicare payers use CMS' resource-based relative value scale (RBRVS) to price their services, so Medicare makes those values available in the fee schedule relative value file - but for these codes , the status indicator is "I," meaning "not valid for Medicare purposes." There was a fall-off among private payers who accepted consult codes right after CMS dropped them, but many payers will still accept them. Providers should check with their plans before billing 99241-99245 to any of them, though, as policy can fluctuate from year to year. UnitedHealthcare, for instance, announced last summer its commercial products would stop accepting consultation codes in October - then backed off at the last minute. The basic purpose of consultation codes hasn't changed: A consultation is when a provider sends a patient to another physician requesting  his or her opinion. Newsome elaborates: "If you're merely giving expertise - seeing the patient to render opinion - it's a consultation. But if you're servicing the patient for a definitive diagnosis or taking over the care, it's not. If you see the cardiologist and he treats you for the diagnosis, that's not [consultation]. A consult by nature is `I'll look and talk to our original physician, and you'll to back to the original physician for treatment.'" Here's how Newsome says you should approach the encounter. "Say I'm a cardiologist, and someone comes with heart murmur," he says. If that patient was referred by his doctor for consultation, "I may take history, review medical records, run additional labs, do chest X-rays, examine him and do all the medical decison-making," says Newsome. "But I don't prescribe anything or do any surgery. I write a report that goes back to the original provider." Newsome likens the role of the consulting physician to a radiologist. "They may interpret and diagnose" without treating the patient, he says.