Billing Medicare for Consult (FAQs)

Can we still use consultation codes CPT 99241-99255, for consultation services provided to non-Medicare beneficiaries?

Answer:
Yes. Therefore, you will want to continue including consultation codes on your superbills, fee tickets and encounter forms to utilize for those payers that still recognize consultation codes. However, if Medicare is a secondary payer and you used a consultation code to bill the primary payer, then Medicare will deny payment on the consultation code as the secondary payer. See further clarification in Question #11

When will Medicare’s payment policy regarding consultation services go into effect?

Answer:
At this time, Medicare will not recognize consultation codes for payment purposes for consultation services provided to Medicare beneficiaries on or after January 1, 2010. Continue coding consultation services provided before January 1, 2010 to Medicare beneficiaries using CPT codes 99241-99255 based on the level of service documented and the patient’s status (inpatient or office). Consultation services provided to Medicare beneficiaries on or after January 1, 2010 must be coded using the appropriate visit codes.

How should consultation services provided to hospital inpatient Medicare beneficiaries on or after January 1, 2010, be coded?

Answer:
Physicians providing consultation services to Medicare hospital patients on or after January 1, 2010 should use the initial hospital care codes 99221-99223 for the first visit during the inpatient stay. The consultant can only bill one initial hospital care code (99221-99223) per beneficiary inpatient stay.

All other visits by the consultant during the inpatient stay should be coded using the subsequent inpatient visit codes 99231-99233.

How should consultation services provided to Medicare beneficiaries in a nursing facility on or after January 1, 2010, be coded?

Answer:
Physicians providing consultation services to Medicare nursing facility patients on or after January 1, 2010 should use the initial nursing facility codes (99304-99306) for the first visit during the patient’s nursing facility stay. The consultant can only bill one initial nursing facility care code (99304-99306) per beneficiary nursing facility stay.

All other visits by the consultant during the Medicare patient’s nursing facility stay should be coded using the subsequent nursing facility codes (99307-99310)

How should consultation services provided to Medicare beneficiaries in the Emergency Room setting on or after January 1, 2010, be coded?

Answer:
Physicians providing consultation services to Medicare patients in the emergency room on or after January 1, 2010 should use the emergency department services codes (99281-99285) based on the level of service provided and documented in the medical record. However, if the patient is admitted to the hospital on the same date as the emergency room visit, then the consultant must use the initial hospital visit codes (99221-99223) instead of the emergency department services codes.

How should we code a consultation service in those cases where the consultant’s documentation of an inpatient consultation does not support coding the lowest level of an initial hospital visit code?

Answer:
Our Medicare J-4MAC, Trailblazer issued a Notice on January 7, 2010 located at: http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=13472 providing further guidance. In this situation you can either bill using code 99499 or the appropriate subsequent hospital visit code for initial hospital consultation services that do not meet any level of an initial hospital visit code. In most cases you may find it less burdensome to use the subsequent hospital visit codes when an initial hospital consultation service fails to meet the documentation requirements to use any of the initial hospital visit codes. If you use CPT 99499 (unlisted service) in those instances where the consultant’s documentation does not support coding the lowest level of an initial hospital visit, the claim will be dropped to paper and a description of the service provided must accompany the claims.

For example, if the consultant only documented a detailed exam and moderate decision making for the initial consultation visit in the hospital setting, which requires documentation of all 3 key components (history, exam and medical decision making), you can use CPT 99499 or CPT 99232 to identify the consultation service.

How will the consultant’s first visit in the hospital be distinguished from the admitting physician’s initial visit in both the hospital and nursing facility setting since the same code sets will be used by both the admitting physician and consultants?

Answer:
Medicare will require the admitting physician (i.e., physician of record) to append modifier “-AI” , Principal Physician of Record, to the initial hospital visit code (99221-99223) or initial nursing facility care code (99304-99306) to distinguish the admitting physician of record from other physicians who may provide a consultation to the beneficiary during the hospital or nursing facility stay. Medicare considers only one physician to be the principal physician of record, the one who oversees the patient’s care from other physicians who may be furnishing specialty care.

CMS has instructed Contractors not to reject claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes.

If the AI modifier is not used by the admitting physician and more than one initial hospital visit/nursing facility visit code is submitted to Medicare, the claim could be subject to medical review and all other initial visit claims during that inpatient stay for the first inpatient/nursing facility day may be held pending review.

There are five (5) inpatient consultation codes, but only three (3) initial hospital visit and initial nursing facility visit codes. For coding purposes, can we use the “crosswalk” created by Medicare that compares the consultation codes to the initial hospital and initial nursing facility visit codes to code consultation services provided after December 31, 2009?

Answer:
Medicare developed the “crosswalk” solely for the purposes of making the budget neutrality calculations required by federal law AND NOT for purposes of providing any guidance or principles on how to code consultations under their new payment policy which eliminates use of the consultation codes. YOU SHOULD NOT USE THE MEDICARE CROSSWALK to code consultation services after December 31, 2009. Rather, utilize the CPT coding criteria for E/M services and the 1995 or 1997 E/M Documentation Guidelines to code consultation services provided to Medicare beneficiaries in the hospital, nursing home and office settings.

For example, if the physician had an initial consultation visit with a Medicare inpatient and documented a comprehensive history, comprehensive exam and moderate decision making, CPT 99222 would be coded to identify the level of consultation service provided.

What happens if a claim is submitted with a consultation code for consultation services provided after December 31, 2009?

Answer:
Medicare will deny payment of any claims submitted with a consultation code for services provided after December 31, 2009. A way to avoid inadvertently billing a consultation code to Medicare is to implement a hard edit within the billing system to stop the claim submission process for any Medicare claims (where Medicare is the primary payer) with a consultation code so staff can review the record and revise the claim to identify the correct CPT code to submit for that consultation service based on the location of the service and the patient’s status.

How should consultation services provided to Medicare beneficiaries in the office setting on or after January 1, 2010, be coded?

Answer:
Physicians providing consultation services to Medicare patients seen in the office should use the appropriate new patient office visit codes (99201-99205) or established office visit codes (99211-99215) depending on the patient’s status. A new patient is one who has not received any professional services (E/M or other face-to-face service) within the previous three (3) years by the provider or anyone within the provider’s billing group.

In all other cases, use the established visit codes (99211-99215). This will result in lower reimbursement as in the past there was no distinction between new and established patients for consultation purposes. Now, however, under Medicare’s new payment policy, if the patient has been seen by the physician or another physician in that group within the last three years, YOU MUST use established visit codes (99211-99215) for any consultations services provided to that patient.

For example, if the provider (or anyone in the physician’s group) has never seen the patient or has not seen the patient within the past three (3) years, then use the new office visit code (99201-99205) for the first visit. However, if the consultant provided a pre-operative consultation at the request of a surgeon, the patient would be established for any consultation services provided within three years from the date of the pre-operative consultation.

Other payers still recognize consultation codes. How will Medicare’s new payment policy, regarding consultation services impact coordination of payment with other payers?

Answer:
At this point there is no definitive response from other payers as to whether they will follow Medicare’s policy. Preliminary comments received from TriWest indicate that they will likely follow Medicare within the next year. In any event, this policy will impact billing when Medicare is not the sole payer. At this time, please be aware of the following issues where other payers do not adopt Medicare’s policy.

• Medicare Primary Payer: You must submit using the appropriate hospital or visit code to receive payment from Medicare. In this case it will be necessary to check with the secondary payers to determine how to bill for those services and receive payment from the secondary payer.
• Medicare Secondary Payer: If the payer still recognizes consultation codes for payment, then the following options are available.
  • Bill the primary payer using a consultation code. If financially beneficiary you can then bill the service to Medicare using the appropriate non-consult E/M code, reporting the amount actually paid by the primary payer along with the appropriate non-consult E/M code to Medicare for determination of whether a payment is due.
  • If the secondary payer allows, the provider can bill using a non-consult E/M code and then report the amount actually paid by the primary payer along with the same E/M code to Medicare for determination of whether a payment is due. In most cases, this will result in a lower level of reimbursement.

If you decide to bill the Secondary Payer using the consultation codes and Medicare denies payment as the secondary payer, YOU CANNOT BILL THE MEDICARE BENEFICIARY FOR ANY AMOUNT THAT WOULD HAVE BEEN PAID BY MEDICARE AS THE SECONDARY PAYER.

What documentation must be in the medical record for consultation services billed to Medicare?

Answer:
Medicare has stated that providers should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting provider. In the hospital setting under the shared medical record, there should still be documentation for the request (i.e., order) and access to the consultant’s notes, which should satisfy Medicare’s documentation requirements, as well as medical necessity for the additional services.

In the office setting, continue to document the identity of the requesting physician along with the clinical reason for the referral. In addition, our Contractor (Trailblazer) has stated that for medical necessity purposes and to justify what would otherwise seem to be redundant physician services, there should be written communication of the results to the requesting provider in the medical record (whether a separate letter or copy of the visit note).

How should consultation services provided to a patient in observation status (not hospital admission) be coded?

Answer:
The physician who ordered a hospital outpatient observation service is the only one who can bill using the observation codes (99217-99220). A TTUHSC physician who provides consultation services while the patient is in observation status must use the appropriate outpatient service codes (i.e., new or established office visit codes).

For example, if an internist orders observation services and asks an endocrinologist to evaluate the patient, the endocrinologist must bill either a new or established office visit as appropriate. See IOM 100-04, Chapter 12, Section 30.6.8

How should consultation services be coded when the patient’s status is changed from inpatient hospital to observation because hospital utilization review determines (and the admitting physician concurs) that the patient should have been admitted as observation rather than hospital admission?

Answer:
If an inpatient hospital patient’s status is changed to observation and the physician provided consultation services before the patient’s status was changed, the consultation services should still be coded using the new or established office visit codes, NOT the initial hospital visit codes. If a patient’s status is changed from inpatient to observation, Medicare will only identify the patient as observation status from the first date of service and therefore would deny any inpatient visit codes billed during that observation time period.

How should consultation services provided to a patient in observation status be coded if the patient’s status is changed to a hospital admission on the same date as the consultation services?

Answer:
If the consultation service is provided on the same date the patient’s status is changed from observation to inpatient hospital and discharged on the same date, use the initial inpatient visit codes (99221-99223).

The patient is admitted to the hospital by an internist in our group who requests a consultation from an endocrinologist who is also a member of the group; can we bill an initial hospital visit for the consultation service provided by the endocrinologist?

Answer:
Yes. CMS stated in MLN Matters Number: MM6740 that Contractors may pay for an initial hospital visit if one physician or qualified Non-Physician Provider (i.e., NP or PA) in a group practice requests an opinion from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.

Can prolonged services codes 99354 and/or 99355 be billed with consultation services billed to Medicare?

Answer:
CMS has outlined “threshold times” for its Contractors to use to determine whether or not the prolonged services codes can be billed with office or other outpatient settings as well as inpatient setting codes. Detailed information regarding these “threshold times” are located in MLN Matters Number MM6740 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf). If prolonged services are billed, there must be appropriate documentation in the medical record to support the time spent face-to-face (not on the floor) with the patient.