The Incredible Disappearing Consultation

In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255 for inpatient). This drastic step was preceded by several years of CMS and its administrative carriers (MACs) attempting to educate the provider community on documentation guidelines for consultations. Unfortunately, CERT audits, and the MAC probe audits those results spawned, showed that providers were still not meeting CMS standards.

In the years since, commercial payers have slowly followed CMS' lead in halting payments for consultations. Beginning October 1, 2017, United Healthcare (UHC) will join this list. In announcing this change in its June 2017 Network Bulletin, UHC based their decision on "extensive data analysis" that "revealed misuse of consultation service codes" for its commercial members. From October 1st and forward, UHC states that it will reimburse "the appropriate evaluation and management (E/M) procedure code" which describes the place of service and the service rendered.

As the reimbursement for consultation codes continues to disappear in the commercial world, providers are faced with a clear choice. Do they chalk it up to "the price of doing business" and abandon consultation codes altogether, or do they focus on being reimbursed for the services by the few commercial payers who are still willing to pay? If their choice is the latter, is it too late to change behavior to work on compliance with documentation standards? Finally, what exactly are those documentation standards?

This can be a lot to unwrap, but by looking at current, available information, the provider community can find an answer. 

A good place to start is UHC's current consultation policy . Despite the fact that it is scheduled for retirement a few months from now, everything in this policy is consistent with other payer policies, as well as wording in the 2017 CPT.

In order to bill for a consultation, a provider must have:

These are, and have been, the rules for consultation codes. In surveying the specific policies of the payers still willing to reimburse for this category of CPT codes, the reader will more than likely not find a dramatic variance from these rules as stated.

In the habitually contentious arena of provider reimbursement, knowledge is power. Consultations may continue to disappear, but connecting the coding compliance dots put forward by the carriers that still pay for them may be the best hope for keeping remuneration flowing a little while longer. 

J. Paul Spencer, CPC, COC
Paul is a Compliance Consultant with our parent organization, DoctorsManagement, LLC

Join NAMAS for the 9th Annual Auditing & Compliance Conference
December 2017 in Orlando, FL!