Consultation Code Update
UnitedHealthcare is aware of and has reviewed the Centers for Medicare and Medicaid Services’
(CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation
codes 99241-99245 or 99251-99255.
In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management
code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims
depending on the status of the patient (new vs. established).
Per CMS, a physician who sees a patient in the hospital should bill an “initial hospital care” code
(99221-99223) for the first visit for Medicare claims. The admitting physician will add
modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC)
to differentiate between the admitting physician and other physicians providing care. All
physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.
Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial
nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting
physician will add modifier AI to their initial nursing facility care service, allowing the MAC to
identify the physician as the admitting physician of record who is overseeing the patient’s care.
All physicians should use the subsequent nursing facility care codes (99307-99310) for their
follow-up care.
CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010
National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment
for, these services.
For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.
For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP®
MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these
plans will follow CMS regulations and implement the change, effective January 1, 2010. The
change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new
coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.
For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for
their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective
January 1, 2010. For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare
commercial position and continue to pay for the consult codes, until directed by each state to
pursue other strategies.
