Explanation of Policy for Billing Consultation Services
Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) removed the consultation codes from the Medicare Physician Fee Schedule (MPFS). The relative value units (RVUs) for the remaining Evaluation & Management codes were increased to compensate for this change.
As a result, physicians will no longer be allowed to bill "consult" codes to Medicare; however, these codes are still valid per the AMA. CMS has already published RVUs for the removed "consult" codes, but going forward, the codes will be published without corresponding rates within the MPFS.
Aetna will continue to recognize these consultation codes.
Since the AMA still lists "consult" codes as active, Aetna will continue to accept and price these codes as valid after January 1, 2010, except as set forth below. We will continue to pay for these codes, according to your Aetna agreement, for members who are covered under our commercial benefits plans and our Medicare Advantage plans. Aetna will also not incorporate the increased RVU values for the remaining Evaluation & Management codes except as noted below.
Consult codes will no longer be paid for some plans
However, we will no longer recognize or pay for consult codes for members covered under our Medicare OpenSM Plan, a Private Fee-for-Service (PFFS) plan, or for claims from nonparticipating providers filing Medicare Advantage claims. Note that the PFFS plan is a non-contracted plan.
UnitedHealthcare is aware of and has reviewed the Centers for Medicare and Medicaid Services’(CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.
In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).
Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.
Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.
CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010 National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.
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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