Medicare Eliminates Consult Codes – What Now?

One of the most significant changes for Medicare billing recently is the elimination of cost for consultation codes. Your institution will have to adjust how you bill for these types of services or you will find a lot of denials.

Just in case you have not had a opportunity to read the newly released fee program (just kidding, it is a lot to read), I have summarized the section on consulting codes below.

Medicare Eliminates Consult Codes – What Now?

Here are the facts about this new ruling and the possible impact on your practice.

1. Consultation codes 99241-99245 (outpatient/office) and 99251-99255 (inpatient) have been eliminated. Tele-health consultation G-codes (G0425-G0427) will not be eliminated.

2. Use codes for new (99201-99205) or established (99211-99215) patients to replace consultations in the office/outpatient setting.

3. Codes in the inpatient hospital setting (99221-99223) should be used to replace inpatient consultation codes (99251-99255), and for nursing premise consultations use codes (99304-99306).

4. To distinguish the dissimilarity between the admitting doctor of report from the consultants for introductory hospital inpatient and nursing premise admissions, Medicare will organize a modifier. Check with your local carrier for more information.

5. Payments for all estimate and administration codes have been increased in an effort to offset the fees lost from the elimination of consultation codes.

An leading note about market or incommunicable insurance. No facts has been released by other third party payers about cost for consultation codes as of yet. However, if your inpatient has Medicare as a secondary payer, a decision will need to be made by the doctor as to how you will report the consultation. Any consultation claim filed with a market insurer such as Blue Cross or Aetna who is primary using the eliminated consultation codes when Medicare is secondary would supervene in a denial for the secondary claim by Medicare. In those instances where Medicare is secondary, you may want to reconsider using the new guidelines as stated above for reporting consultation codes.

One more note. If you have not updated your enrollment facts with Medicare since November 2003, you must do so. Although enrolled in Medicare, many physicians who are eligible to refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment report is one that is in the Medicare provider enrollment, chain and proprietary ideas (Pecos) and also contains the physician’s national provider identifier (Npi).

Follow these few straightforward guidelines and you should have no question being paid for consulting codes.

Medicare Eliminates Consult Codes – What Now?