Changes to consultation codes

For several years, CMS has argued that physicians were not using consultation codes properly. They were using such codes in situations where patients were self-referred, where no documentation of consultation was evident from the referring source’s chart or where the physician was expected to assume care of part or all of the patient’s problems at the first encounter (the so-called transfer of care). Despite opposition from the specialty societies, in the final rule, CMS has decided to stop making payments for consultation services starting January 1, 2010, stating that in most cases, there is no substantial difference in work between consultations and visits. CMS directs that the inpatient consultation codes (99251-99255) will now be reported with the 99221-99233 inpatient initial admission service codes. In the office setting, the consultation codes (99241-99245) should be reported with codes from the 99201-99205 series if the patient is new or has not been seen within three years for a face-to-face Evaluation and Management (E/M) encounter, and with codes 99212-99215 if the patient has been seen within three years.

As of January 1, 2010, claims with consultation codes for Medicare fee-for-service beneficiaries will be rejected by the Medicare contractors and will need to be resubmitted with different E/M codes as described above. These errors will not be cross walked by contractors to the allowed codes. How bills to Medicare as a secondary insurer will be handled is not clear. Commercial plans and Medicaid are still expected to recognize consultation code billings. If members hear of examples to the contrary, the GI societies should be informed so that our advocacy efforts can be applied.