CPT Code Description 99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Medicare wont cover Consult code hence use appropriate other E & M code., read below The documentation for this encounter requires THREE out of THREE of the following : 1) Comprehensive History Or 60 minutes spent face-to-face with the patient if coding based on time. The appropriate documentation must be included. |
• All of the criteria for the use of a consultation code are met;
• The consultation is followed by treatment;
Medicare Payment Rules for Consultation Services
Medicare no longer recognizes consultation CPT codes 99241-99245 and 99251-99255. This applies for both Medicare-primary and Medicare-secondary claims. Please Note: These codes are still valid CPT codes for 2010, and Blue Cross continues to accept these consultation codes. We have current allowable charges for these codes and any changes in allowable amounts or billing policies for these codes will be communicated to our providers with a 90-day notice. At this time, we do not anticipate any changes.
Per CMS, physicians and others must bill an appropriate Evaluation and Management code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and others billing for these services may either:
1. Bill the primary payer an Evaluation and Management code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same Evaluation and Management code, to Medicare for determination of whether a payment is due; or
2. Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an Evaluation and Management code that is appropriate for the service, to Medicare for determination of whether a payment is due.
Note: The first option may be easier from a billing and claims processing perspective.
BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:
99241 to 99212
99242 to 99212
99243 to 99213
99244 to 99214
99245 to 99215
Consultation Services
A consultation is an evaluation and management service provided at the request of another provider for the evaluation of a specific condition or illness.
Consultation Procedure Codes
3-99241 3-99242 3-99243 3-99244 3-99245
3-99251 3-99252 3-99253 3-99254 3-99255
A consultation must consist of the following in order to be billed as such:
There must be a request from the referring provider for the evaluation of a particular condition or illness.There must be correspondence from the consulting provider back to the referring provider indicating his medical findings. During a consultation, the consulting provider may initiate diagnostic and therapeutic services if necessary.
Separation of CPT and Non-CPT Information Consultations
CPT CODES: 99241-99243, 99244-99255
The CMS concurs with American Medical Association “Current Procedural Terminology (CPT)” guidelines related to physician reporting of inpatient and outpatient consultation services 99241-99243, 99244-99255
99241 Office consultation for a new or established patient, which requires these three key components:
• a problem focused history;
• a problem focused examination; and
• straightforward medical decision making Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99242 Office consultation for a new or established patient, which requires these three key components:
• an expanded problem focused history;
• an expanded problem focused examination; and
• straightforward medical decision making
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
The CMS will pay a consultation fee when the service is provided by a physician at the request of the patient’s attending physician when:
• All of the criteria for the use of a consultation code are met;
• The consultation is followed by treatment;
• The consultation is requested by members of the same group practice;
• The documentation for consultations has been met (written request from an appropriate source and a written report furnished the requesting physician);
• Pre-operative consultation for a new or established patient performed by any physician at the request of the surgeon; and
• A surgeon requests that another physician participate in post-operative care (provided that the physician did not perform a pre-operative consultation). Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
UnitedHealthcare – Overview
This policy discusses how UnitedHealthcare evaluates CPT(®) consultation codes 99241-99245 and 99251-99255 and HCPCS codes G0406-G0408 and G0425-G0427 for reimbursement.
Reimbursement Guidelines
Consultation Services
The American Medical Association (AMA) Current Procedural Terminology (CPT ®) book describes a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.
Services initiated by a patient and/or family and not requested by a physician or other appropriate source should not be reported using CPT consultation codes 99241-99245 or 99251-99255 or HCPCS consultation codes G0406-G0408 or G0425-G0427, but may be reported using appropriate office visit, hospital care, home service or domiciliary/rest home care codes.
UHC Community Plan Medicaid:
UnitedHealthcare Community Plan will consider a claim for a consultation service for reimbursement for Medicaid members if the requesting or referring provider or other appropriate source is identified on the claim. If the requesting or referring entity is not identified on the claim, the consultation service will be denied because it does not meet basic AMA requirements for reporting such a code.
Note: AMA guidelines state that only one inpatient consultation (99251-99255) should be reported by a consultant per admission. Evaluation and Management (EM) services after the initial consultation during a single admission should be reported using non-consultation EM codes. UHC Community Plan Medicare:
Effective January 1, 2010 CMS ceased reimbursing Evaluation and Management (E/M) codes describing consultation services (CPT 99241-99245 and 99251-99255) in all places of service. The codes were assigned a status indicator of “I” beginning with the January 2010 National Physician Fee Schedule (NPFS). Therefore, UnitedHealthcare Community Plan will not reimburse consultation codes 99241 – 99245 or 99251-99255 for Medicare members. HCPCS consultation codes G0406-G0408 or G0425- G0427 will be considered for reimbursement for Medicare members if the requesting or referring provider or other appropriate source is identified on the claim.
Consult code basics
type of service (CPT codes 99241-99275) provided by a physician whose
opinion or advice regarding evaluation and/or management of a specific
problem is requested by another physician or other appropriate source. A
physician consultant may initiate diagnostic and/or therapeutic
services.
The request for a consultation from the
attending physician or other appropriate source and the need for
consultation must be documented in the patient’s medical record. The
consultant’s opinion and any services that were ordered or performed
must also be documented in the patient’s medical record and communicated
to the requesting physician or other appropriate source.
A
consultation initiated by a patient and/or family, and not requested by
a physician, is not reported using the initial consultation codes but
may be reported using the codes for confirmatory consultation or office
visits, as appropriate.
Any procedure that can be
identified with a specific CPT code performed on or subsequent to the
date of the initial consultation should be reported separately.
If
a consultant subsequently assumes responsibility for management of a
portion or all of the patient’s condition(s), the consultation codes
should not be used.
However Medicare and Medicare HMO
does not accept consultation code in 2010. Please see the previous post
related on consultation code update from Medicare.
Consultants and Inpatient Concurrent Care
A
consultant may become a concurrent care provider on a case if his/her
services after the consultation are necessitated by the condition of the
patient, and meet the reasonableness test for standard of care. The
consultant may bill for the initial consultation (if it meets the
definition of a consultation described in the “Consultations” section of
this manual), but not for additional consultations, as he/she cannot be
both a consultant and a concurrent care provider on the same case.
Subsequent care after the initial consultation should be submitted as the appropriate level hospital inpatient service.
If,
after consultation, the surgeon’s role is assumed by the consultant,
the consultant may bill for neither additional consultations nor
follow-up care, as the global surgery period policy (GSP) supersedes
this policy.
