CMS Eliminates Consultation Payments

Postponement of the Medicare fee cuts until March by Congress on Dec. 19 does not affect other payment policies included in the 2010 Centers for Medicare & Medicaid Services (CMS) physician fee schedule. They will take effect on schedule on Jan. 1.

Those policies include revisions to the consultation services payment policy [ PDF ]. CMS will no longer pay physicians for consultations using the CPT consultation codes. The consultation codes comprise 99241-99244 for office or other outpatient consults and 99251-99255 for inpatient consultations. Instead, CMS instructed physicians to bill using the new or established patient codes. The link above provides details on the new policy and describes how physicians should bill Medicare for consults. 

The American Medical Association asked CMS to delay the consultation policy for a year. CMS has not acted on the request.

TMA's payment advocacy staff developed answers to these frequently asked questions about the consultation codes:

Q. Are the commercial carriers planning to follow the CMS elimination of consultation codes?

A. At this time, none of the commercial carriers have issued guidance regarding elimination of consultation codes. As soon as we receive responses, we will share them with TMA members.

Q . Is there a modifier to indicate the principal physician of record for inpatient visits?

A . Yes. CMS guidance from the  MLN Matters Number MM6740 [ PDF ] article says, "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."

Q. If the patient's primary insurance still accepts consultation codes and their secondary insurance is Medicare, how should I bill the service?

A . CMS guidance says you may bill one of two ways:

  • 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.

Action , Dec. 31, 2009


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