cpt code 99241, 99242, 99243, 99244, 99245 - Medicare Billing and Coding Guide

procedure code and description

99241 - Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are selflimited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99242 Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-toface with the patient and/or family.


99243  Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.


99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99245 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. Average payment - $210 - $250

Office or Other Outpatient Consultations: Office or other outpatient consultations are reported with procedure  codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting.

A. Initial Consultation

1. In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation procedure ? codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission.

2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation procedure ? codes 99241-99245 for the initial consultation service.

3. A consulting physician or other qualified health care professional may initiate diagnostic services and treatment at the initial consultation service or may even take over the patient’s care after the initial consultation.

Follow-up Services

1. Ongoing management, following the initial consultation service by the consulting physician or other qualified health care professional should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service.

2. In the hospital setting, following the initial consultation service, the subsequent hospital care procedure ? codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care procedure ?codes 99307-99310 should be reported for additional follow-up visits.

3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient procedure ? codes 99212-99215 should be reported for additional follow-up visits.

4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or other appropriate source and documented in the medical record, the office or outpatient consultation  procedure ? codes 99241- 99245 may be used again.  

Consultation Services

CPT Codes 99241–99255 were clarified in Change Request 4215 by the Centers for Medicare & Medicaid Services regarding the definition of a consultation:

When and by whom a consultation may be reported;

Clarification that a split/shared visit may not be performed or reported as a consultation service;

Verification that qualified non physician practitioners (NPPs) can perform consultations when requirements are met; and Revised and updated consultation examples

Note: CPT codes 99261-99263 (hospital inpatient follow-up consultations) and CPT codes 99271-99275 (confirmatory consultations) were deleted effective for services on and after January 1, 2006.

Evaluation and Management CONSULTATIONS (Codes 99241-99245)

When to Code an Evaluation and Management Service as a Consultation One of the most frequently asked questions is how to determine if an evaluation and management (E/M) service is a consultation. The discreet difference between a consultation and an office visit is that a consultation is provided by a practitioner whose opinion or advice regarding evaluation and/or
management of a specific problem is requested by another practitioner. An office visit is deemed a consultation only when the following criteria for the use of a consultation code are met: 


1. Consultation is being performed at the REQUEST of another practitioner or appropriate source requesting advice regarding evaluation and/or management of a specific problem 

2. The request for the consultation and the reason for the request must be RECORDED in the patient’s medical record.

3. After the consultation is provided, the practitioner must prepare a written REPORT of his or her findings, which is provided to the referring practitioner.

If all the listed requirements are not met then the appropriate office or other outpatient (99201-99215) or hospital inpatient (99221-99223) E/M service should be reported instead of a consultation code. 

Some of the confusion in coding consultations begins with the terms used to describe the requested  service. The word ‘consultation’ and the word ‘referral’ are sometimes incorrectly considered one and the same. When a practitioner refers a patient to another practitioner, it cannot be automatically considered a consultation. The service can only be considered a consultation if the above criteria are met in the service provided. A service provided to a patient who was referred to another practitioner without written or verbal request for a consultation (which is documented in the patient’s record)
should be coded using one of the office or other outpatient codes or hospital care codes.

The decision to request a consultation is exclusively up to the requesting practitioner. The medical necessity for a consultation is dependent on the clinical judgment of the practitioner. Once the requesting practitioner receives the report from the consulting practitioner, he or she may either continue to manage the patient’s condition or request the consulting practitioner to take over the management of the patient’s condition from that point forward. If the consulting practitioner chooses to accept management of the patient’s condition after the consultation has been completed, the appropriate code from the office or other outpatient or hospital inpatient should be used for any further E/M services provided.

Medicare deleted code 99241,  99245 Guide

Change Request (CR) 6740 alerts providers that effective January 1, 2010, the Current Procedural Terminology (procedure ) consultation codes (ranges 99241-99245 and 99251- 99255) are no longer recognized for Medicare Part B payment.

• CR6740 removes all references (both text and code numbers) in the Medicare Claims Processing Manual, Chapter 12, Section 30.6 that pertain to the use of the American
Medical Association (AMA) procedure  consultation codes (ranges 99241-99245 and 99251- 99255).

• Providers should code a patient E/M visit with E/M codes that represents WHERE the visit occurs and that identify the COMPLEXITY of the visit performed.


United Healthcare Update Consultation Codes

** United Healthcare will align with the Centers for Medicare & Medicaid Services (CMS) and no longer reimburse consultation services represented by CPT codes 99241-99245 and 99251-99255.

** This update is effective for claims with dates of service on or after Oct. 1, 2017

** United Healthcare will reimburse the appropriate evaluation and management (E/M) procedure code which describes the office visit, hospital care codes reported in lieu of a consultation services procedure code.

** This notification will be the first of several communications to clarify this change in reimbursement strategy supporting the commitment to the triple aim of improving health care services, health outcomes and overall cost of care.

** Intially when CMS made an original decision to no longer recognize these consultation services procedure codes, United Healthcare began pursuit of data analysis and trending to better understand the use of consultation services codes as reported in the treatment of our commercial members.

** UHC has revealed misuse of consultation services codes by extensive data analysis on consultation codes similar to CMS‟s findings

** The current Relative Value Unit (RVU) assignments reflect numerous changes made during recent years to both E/M codes and other surgical services creating an overall budget neutral experience supporting this strategy as a more accurate reflection of services rendered.


CONSULTATION CROSS WALK CODES
Inpatient (POS 21) Office POS 11/Out Patient (POS 22)
Consults Crosswalk Consults Crosswalk

99251 99221 99241 99201/99212
99252 99221 99242 99202/99213
99253 99221 99243 99203/99213
99254 99222 99244 99204/99214
99255 99223 99245 99205/99215

Key points in CR6740

• Effective January 1, 2010, local Part B carriers and/or A/B MACs will no longer recognize AMA procedure  consultation codes (ranges 99241-99245, and 99251-99255) for inpatient facility and office/outpatient settings where consultation codes were previously billed for services in various settings.

• Effective January 1, 2010, local FIs and/or A/B MACs will no longer recognize AMA procedure  consultation codes (ranges 99241-99245, and 99251-99255) for Method II CAHs, when billing for the services of those physician and non-physician practitioners who have reassigned their billing rights.

• Physicians may employ the 2009 consultation service codes, where appropriate, to bill for consultative services furnished up to and including December 31, 2009.

• Providers who bill an E/M service after January 1, 2010, using one of the procedure   consultation codes (ranges 99241-99245 and 99251-99255) will have the claim  returned with a message indicating that Medicare uses another code for reporting  and payment of the service. To receive payment for the E/M service, the claim should be resubmitted using the appropriate E/M code as described in this article. Although the Centers for Medicare & Medicaid Services (CMS) has eliminated the use of the procedure  consultation codes for payment of E/M services furnished to Medicare fee-for-service patients, those E/M services themselves continue to be covered services if they are medically reasonable and necessary and, therefore, an ABN is not applicable. Furthermore, the patient may not be billed for the E/M service instead of Medicare.

• RHCs and FQHCs will discontinue use of AMA procedure  consultation codes 99241- 99245 and 99251-99255 and should instead use the E/M codes that most appropriately describe the E/M services that could be described by the procedure  consultation codes.

• Conventional medical practice is that physicians making a referral and physicians accepting a referral would document the request to provide an evaluation for the patient. In order to promote proper coordination of care, these physicians should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting physician. This is not to be confused with the specific documentation requirements that previously applied to the use of the consultation codes.

• In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs that perform an initial evaluation may bill an initial hospital care visit code (procedure   code 99221 – 99223) or nursing facility care visit code (procedure  99304 – 99306), where appropriate.

• In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.

• The principal physician of record will append modifier “-AI” (Principal Physician of 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.

• For patients receiving hospital outpatient observation services who are not subsequently admitted to the hospital as inpatients, physicians should report procedure   codes 99217-99220. In the event another physician evaluation is necessary, the physician who provides the additional evaluation bills the office or other outpatient visit codes when they provide services to the patient.

For example, if an internist orders observation services, furnishes the initial evaluation, and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established patient office or other outpatient visit codes as appropriate.

• For patients receiving hospital outpatient observation services who are admitted to the hospital as inpatients and who are discharged on the same date, the physician should report procedure  codes 99234-99236 (e.g., code 99234 - Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date). If the patient is an inpatient and another physician evaluation is necessary, the physician would bill the initial hospital day code as appropriate (99221-99223). Otherwise, the physician should use the new or established patient office or other outpatient visit codes for a necessary evaluation.

• For patients receiving hospital outpatient observation services who are admitted to the hospital as inpatients on the same date, the physician should report only the initial hospital care services codes (codes 99221 - 99223). Medicare will pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of  admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Medicare will pay the office visit as billed and the Level 1 initial hospital care code. The principal physician of record, as previously noted, must append the “-AI” modifier to the claim with the initial hospital care code.

• For patients receiving hospital outpatient observation services or inpatient care services  including admission and discharge services) for whom observation services are initiated or the hospital inpatient admission begins on the same date as the patient’s discharge, the ordering physician should report procedure  codes 99234-99236.

• If the emergency department (ED) physician, based on the advice of the patient’s personal physician who came to the ED to see the patient, sends the patient home, then the ED physician should bill the appropriate level of ED service (ED visit codes 99281 - 99288). The patient’s personal physician should also bill the level of ED code that describes the service he or she provided in the ED. 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. 

• If the ED physician requests that another physician evaluate a given patient, the other physician should bill an ED visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an ED visit code.

• Follow-up visits by the physician in the facility setting should be billed as subsequent hospital care visits for hospital inpatients and subsequent nursing facility care visits for patients in nursing facilities, as is the current policy.

• In the office or other outpatient setting where an evaluation is performed, physicians and qualified NPPs should report the procedure  codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.

• A new patient is a patient who has not received any professional services (E/M or other face-to-face service) within the previous three years. Examples of where a new patient office visit is not billable:

• If the consultant furnishes a pre-operative consultation at the request of a surgeon on a beneficiary, and the consultant has provided a professional service to the patient within the past three years, then this situation would not meet the requirements to bill a new patient office visit.

• The consultant could not bill for a new patient office visit for a consultation furnished to a known beneficiary for a different diagnosis than he or she has previously treated if the patient was seen by the consultant in the prior three years.

• The consultant furnishes a consultation to a known beneficiary in an outpatient setting different than the office (e.g., ED observation where the patient was seen in
the past three years). As the patient has been seen by the consultant within the past three years, a new patient office visit cannot be billed. 

• In order for physicians to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet procedure ’s definition of a comprehensive history).

• Medicare may pay for an inpatient hospital visit, an office visit, or other outpatient visit if one physician or qualified NPP in a group practice requests an evaluation and management service from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.

• Medicare will also no longer recognize the consultation codes for purposes of determining Medicare secondary payments (MSP). In MSP cases, physicians and others must bill an appropriate E/M 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: 

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

• 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 E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due. 



No comments:

Medical Billing Popular Articles