Consult code billing update and billing rules

CONSULTATION SERVICES

Effective for services furnished on or after January 1, 2010, Medicare no longer recognizes inpatient consultation codes (Procedure  codes 99251–99255) and office and other outpatient consultation codes (Procedure  codes 99241–99245) for Part B payment purposes.


However, telehealth consultation codes (Healthcare Common Procedure Coding System G0406–G0408 and G0425–G0427) are recognized for Medicare payment. Physicians and NPPs who furnish services that, prior to January 1, 2010, would have been reported as Procedure  consultation codes, should report the appropriate E/M visit code to bill for these services beginning January 1, 2010.


Medicare Payment Rules for Consultation Services

Medicare no longer recognizes consultation CPT codes 99241-99245 and 99251-99255. This applies for both Medicare-primary and Medicare-secondary claims. Please Note: These codes are still valid CPT codes for 2010, and Blue Cross continues to accept these consultation codes. We have current allowable charges for these codes and any changes in allowable amounts or billing policies for these codes will be communicated to our providers with a 90-day notice. At this time, we do not anticipate any changes.

Per CMS, physicians and others must bill an appropriate Evaluation and Management code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and others billing for these services may either:

1. Bill the primary payer an Evaluation and Management code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same Evaluation and Management code, to Medicare for determination of whether a payment is due; or

2. Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an Evaluation and Management code that is appropriate for the service, to Medicare for determination of whether a payment is due. 

Note: The first option may be easier from a billing and claims processing perspective. 

For more on this from the CMS, go to www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/SE1010.pdf.


1. Consult and preventive codes

Usually we could not bill consult code and preventive code together.


2. Consult code for place of service 22

   Should not file the consultation code claims with POS 22.


3. Consult codes 2010 for horizon blue cross blue shield

   We can file the consult code to Horizon blue cross blue shield


4 Consult codes for medicaid

We can file the consult code to Medicaid


6. Consult codes for medicare advantage plans

    Medicare advantage plans do not cover the consultation service.


7. Consult codes not accepted by commercials in Florida

   We can file the consult code to some commercial insurance in Florida. 


8. Consult with preventive billing

     We could not file the preventive code with consultation.


9. Consultation and office visit billed together

       We cannot bill the consultation code and office visit together for the same date of service.


10. Consultation code-99251-99255 accepted by medicare hmos

     Medicare HMO plan does not cover the consultation service.


     
S.No
Insurance name
1
Medicare
2
Humana (HMO)
3
Freedom Health
4
AVMED
5
Advantra Gold plus ( Coventry )
6
Universal Health
7
Wellcare
8
AARP Medicare completed
9
UHC (HMO)
10
Polk County
11
PUP
12
QHP
13
Amerigroup
14
Citruscare

11. Consultation codes list

    Office consultation code
    99241
    99242
    99243
    99244
    99245

*      Hospital Consultation code

99251
99252
99253
99254
99255

12. Consult code payment 2010 insurance

  Below I have mentioned few insurance that we have received the payment for consult code

Aetna
BCBS
Cigna
Great West
Tricare
Golden Rule
Medicaid
UHC (Commercial non-HMO plans)

13. Consult codes coding billed with code 96372

   We can file CPT 96372 along with Consultation code. And 96372 is injection admin code

14. Consult CPT code used by Aetna 2010

  Aetna will processes the below set of consultation code.
    Office – 99241 to 99245
    Hospital – 99251 to 99255

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