Medicare Eliminates Consult Codes – What Now?

One of the most significant changes for Medicare billing recently is the elimination of payment for consultation codes. Your practice will have to adjust how you bill for these types of services or you will find a lot of denials.

Just in case you have not had a chance to read the newly released fee schedule (just kidding, it is a lot to read), I have summarized the section on consulting codes below.

Here are the facts regarding this new ruling and the potential impact on your practice.

1. Consultation codes 99241-99245 (outpatient/office) and 99251-99255 (inpatient) have been eliminated. Tele-health consultation G-codes (G0425-G0427) will not be eliminated.

2. Use codes for new (99201-99205) or established (99211-99215) patients to replace consultations in the office/outpatient setting.

3. Codes in the inpatient hospital setting (99221-99223) should be used to replace inpatient consultation codes (99251-99255), and for nursing facility consultations use codes (99304-99306).

4. To distinguish the difference between the admitting physician of record from the consultants for initial hospital inpatient and nursing facility admissions, Medicare will develop a modifier. Check with your local carrier for more information.

5. Payments for all Evaluation and Management codes have been increased in an attempt to offset the fees lost from the elimination of consultation codes.

An important note regarding commercial or private insurance. No information has been released by other third party payers regarding payment for consultation codes as of yet. However, if your patient has Medicare as a secondary payer, a decision will need to be made by the physician as to how you will report the consultation. Any consultation claim filed with a commercial insurer such as Blue Cross or Aetna who is primary using the eliminated consultation codes when Medicare is secondary would result in a denial for the secondary claim by Medicare. In those instances where Medicare is secondary, you may want to consider using the new guidelines as stated above for reporting consultation codes.

One more note. If you have not updated your enrollment information with Medicare since November 2003, you must do so. Although enrolled in Medicare, many physicians who are eligible to refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare provider enrollment, chain and ownership system (PECOS) and also contains the physician’s national provider identifier (NPI).

Follow these few simple guidelines and you should have no problem being paid for consulting codes.