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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Consultation Coding

November 1st, 2012

CMS (the Centers for Medicare and Medicaid Services) announced the elimination of consult codes from the Medicare fee schedule that went into effect January 1, 2010, requiring doctors to 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 released in the 2010 CPT manual. Specific changes include 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. Some important points to note:

  • The policy only applies to physicians billing the Medicare fee-for-service program. It does not apply to Medicare Advantage or non-Medicare insurers.
  • In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT code 99221 - 99223) or nursing facility care visit code (CPT 99304 - 99306), where appropriate. This means more than one provider can report a code in the 99221 - 99223 range on the same day for the same patient. The principal physician of record will append modifier "-AI" Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient will bill only the E/M code for the complexity level performed. However, claims that include the "-AI" modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.
  • Emergency department visits (codes 99281 - 99288) - physician billing for emergency department services provided to patient by both patient's personal physician and emergency department (ED) physician. If the ED physician, based on the advice of the patient's personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient's personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient's personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient's personal physician may not bill.

Along with the AMAs 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 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.

For more guidance on reporting consultation services to Medicare see the January 2010 AAOMS Advocacy e-Newsletter and related article on the Practice Management pages of the AAOMS web site. For additional information be sure to read the CMS Transmittal and MLN Matters articles MM6740 and SE1010. The AAOMS will continue to monitor this issue to keep you informed.