Practice Management & Allied Staff News & Materials
AMA and MACs Guidance on Reporting Consultation Codes
November 21st, 2011
CMS (the Centers for Medicare and Medicaid Services) announced the elimination of consult codes from the Medicare fee schedule effective January 1, 2010, requiring doctors to instead bill for either new or established office visits . The American Medical Association (AMA) has since issued information and guidance for reporting consultation services to non-Medicare payers. The guidance explains revisions to the consultation code guidelines in the 2010 CPT manual. Specific changes include new explanations of the appropriate use of office consultation codes 99241-99245 and inpatient consultation codes 99251-99255; revision of the concurrent care definition in the Definitions of Commonly Used Terms section of the E/M guidelines; and revision of the Outpatient Consultation, Inpatient Consultation, and the overarching Consultation guidelines.
Along with the AMA's information, several local Medicare Administrative Contractors (MACs) have issued more specific guidance. The issue some MACs have attempted to address is that the two lowest level inpatient consultation codes, 99251 and 99252, do not have good crosswalks to the initial hospital care codes 99221 - 99223. For example, Wisconsin Physician Services (WPS), the MAC for Iowa, Kansas, Missouri and Nebraska), is advising providers to report unlisted evaluation and management code 99499 when documentation does not support a 99221-99223. First Coast (MAC for Florida, Puerto Rico and U.S. Virgin Islands) and Palmetto GBA (MAC for California, Hawaii and Nevada; and the carrier for Ohio) have put out similar guidance. Trailblazer (MAC for Colorado, New Mexico, Oklahoma and Texas), on the other hand, says you bill a subsequent hospital visit code (99231-99233) when the work doesn't meet documentation or medical necessity requirements for an initial hospital visit (99221-99223) leaving 99499 (unlisted E/M) as an alternate option. As such, it is important that OMSs are familiar with their local MACs' policies when it comes to billing inpatient consultation services.