In recent years, private payors have followed suit: Health Net no longer reimburses consultation services and UnitedHealthcare has announced its intention to stop recognizing the consult codes, as well. For all other Medicaid states, however, AmeriChoice currently follows the UnitedHealthcare commercial position and will continue to pay for consult codes until directed otherwise by a state to pursue other strategies. I agree with all of the comments made but look at hte bright side. 219 40 According to the author, Joel I. Shalowitz, MD, MBA, Consultation codes are being billed erroneously at a high rate. <> They published this in July 2008 and all societies were aware of the change coming. 0000005777 00000 n Many commercial insurance companies still recognize consults. professional who has agreed to accept transfer of care before an initial evaluation. Outpatient consultations (9924199245) and inpatient consultations (9925199255) were still active CPT codes, and depending on where you are in the country, are recognized by a payer two, or many payers. endobj My question to you is are you meeting all three requirements of a consultation? The consultants opinion and any other services that were ordered or performed must also be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.. %PDF-1.7 % Neglecting to bill consults when the carrier pays them results in lost revenue. I am looking for information that the insurance companies have put on there web sites. The reason why Medicare and now most payers don't pay for "consultation" codes is that there were not being used correctly. 234 0 obj The requirements for a consultation have not changed. Consult Codes The list we have is BCBS, Aetna, Work Comp, and Auto only. According to CPT, these codes are used for new or established patients. After CMS eliminated the codes Jan. 1, private payers could choose to continue reimbursing the codes or follow CMS's lead. 2. I am looking for information that the insurance companies have put on there web sites. 0000028068 00000 n Get access to CodingIntel'sfull library of coding resourceswith a low-cost membership TODAY. A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.. <>/Filter/FlateDecode/Index[26 193]/Length 29/Size 219/Type/XRef/W[1 1 1]>>stream Please recall that CMS/Medicare and several other payers still do not recognize or accept consultation codes, and we do not anticipate that this would change during a public health emergency. AiE1qi V $`p_p4O- I just heard yesterday that CMS may be reconsidering on the Consult codes. At first, most continued accepting the codes. 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For Medicare, which does not accept consultation codes, guidelines state that you are required to use 99281-99285, as the post above indicates. endobj 0000007877 00000 n Refer to the following documents for Blue Shield's payment processing logic and procedure codes: Blue Shield Payment Processing Logic (PDF, 18 KB) Hospital Acquired Condition (HAC)/Never Events Codes (Excel, 346 KB) Effective 10/01/2022 - 09/30/2023. The citation from the Medicare Claims Processing Manual is at the end of this Q&A. Dont make the mistake of always using subsequent care codes, even if the patient is known to the physician. Other carriers are following suit. If you provide consultations to Cigna members, be aware that Cigna will soon no longer pay those codes. For an inpatient service, use the initial hospital services codes (9922199223). <> They wont know. In the past, the codes 99221-99223 were used only for the admitting physicians, and the codes 99251-99255 were . Assuming you meet the coding definition of consult, if 98% of your consult codes get denied, that does not seem like a great way to get paid. A consultation is provided by a physician or qualified healthcare professional at the request of another physician, qualified healthcare professional, or other professional source. And, with it, there is a consultation codes update for 2023. She has been a self-employed consultant since 1998. When you look in your book, notice that CPT has entirely removed the concept of transfer of care. 0000003057 00000 n When CMS stopped paying for consults, it said it still recognized the concept of consults, but paid for them using different categories of codes. 228 0 obj P`LS=$6XSEzH.TD1 Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the providers first E/M service to the inpatient during the hospital stay. 0000003366 00000 n endobj 221 0 obj Only the preventive medicine E/M service code, reported with ICD-10 codes . Use either medical decision making or the practitioners total time on the date of the visit to select the level of service. Cigna will become the second payer to discontinue payment for consultation services in 2019. In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. The correct start date is March 1, 2022. The question is, how should they be billed? 0000006009 00000 n #3. Hope this helps! Invalid Service Facility Address. Most groups suggest that their clinicians continue to select and document consults (when the service is a consult) whether or not they know if the payer recognizes consults or not. Does anyone have a list of commercial insurance companies that are still accepting consult codes and one that are following medicare guidelines? endobj 75% of consult are inappropriate, I guess this was doctors own doing. Consultation Codes Update, October 2022: The CPT books have arrived! <>stream <> 227 0 obj Bill primary payer consult codes: Your second choice is to bill the primary payer using the consult codes. what is the best way to check how this change affects the HMO plans? endobj If youre wondering why CMS initiated the change in policy in the first place, you may want to readthe article Is it Time to Eliminate Consultation Codes? in the Archives of Internal Medicine. 0000028304 00000 n Watch out with BCBS especially because if you code an initial hospital visit when it was actually a consult (as is the common practice with any other payer), they will recoup their payment and you'll have to resubmit a corrected claim. please indicate your agreement by clicking below on the button labeled "I Accept". Some physician practices billing consultation codes (99241-99245, 99251-99255) to private payers running Medicare Advantage plans have recently reported receiving denials. They are used to help identify whether health care services are correctly coded for reimbursement. C CatchTheWind Guest 0000001415 00000 n <>/MediaBox[0 0 612 792]/Parent 23 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Here's how to crosswalk the consult codes to E/M codes based on MDM or time: E/M based on MDM Why not just make the rules clearer before getting rid of them altogether? 0000063843 00000 n Coding and Modifier Information 0000004462 00000 n <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences 221 0 R>> endobj They set up an edit in their system so that consult codes can be reviewed and cross walked to the appropriate code, depending on the payer. xref %%EOF Many commercial plans continue to reimburse for consultation services. The AMA has extended the framework for office and outpatient services to consults in 2023. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. An example of upcoding is an instance when you provide a follow-up office visit or follow-up inpatient consultation but bill using a higher level E&M code as if you had provided a comprehensive new patient office visit or an initial inpatient consultation.
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