Consultations After Elimination of Payments for Evaluation and Management Consultation Codes

A consultation service provides expert opinion or advice at the request of another provider. The Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for the outpatient and inpatient consultation codes traditionally used to report these services (CPT 99241-99245 and 99251-99255, respectively), and private payers are likely to follow suit. CMS has instead mandated that these services are mapped to new or established visit codes for outpatients (99201-99205 or 99212-99215) and to initial or subsequent hospital services codes for inpatients (99221-99223 or 99231-99233). This article reviews appropriate medical consultation and provides specific guidance for the reporting of these services to CMS and other payers not reimbursing consultation codes.

Abbreviations: CMS = Centers for Medicare and Medicaid Services; CPT = Current Procedural Terminology; E/M = evaluation and management; RVUs = relative value units

In the routine care of patients, clinical questions arise for which a treating physician obtains expert opinion by requesting a consultation. Integral to medical practice for millennia, consultations will remain an important part of future health care delivery. The Current Procedural Terminology (CPT) evaluation and management (E/M) codes used to bill consultation services have existed for approximately 20 years. Through this time, contention existed between physicians and both the Centers for Medicare and Medicaid Services (CMS) and other payers regarding related policy and documentation issues, and the coding system has undergone a number of revisions. In a March 2006 Office of Inspector General report, approximately 75% of  reviewed, paid consultations did not meet all applicable program requirements,i resulting in improper Medicare payments exceeding $500 million annually. Recent Highmark Medicare Services reviews in 2009 found that in Washington, DC, 89% of 99255 (Inpatient Consultation level 5) and 89% of 99245 (Outpatient Consultation level 5) were billed incorrectly; in Maryland, 86% of 99245 were billed incorrectly.

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