Medicare No Longer Pays for CPT Consultation Codes

Medicare no longer pays for the CPT consultation codes (ranges 99241-99245 and 99251-99255), as of Jan. 1, 2010. Instead, you should code a patient evaluation and management (E&M) visit with E&M codes that represent where the visit occurs and that identify the complexity of the service performed.

  • When performing an evaluation in the office or other outpatient setting, you should report CPT codes 99201-99215, depending on the complexity of the visit and whether the patient is a new or established patient.
  • The principal physician of record should append modifier AI, "principal physician of record" to the E&M code when billed. This modifier distinguishes 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.
  • When you perform an initial evaluation in the inpatient hospital or nursing facility setting, you may bill an initial hospital care visit code (CPT codes 99221-99223) or nursing facility care visit code (CPT codes 99304-99306), where appropriate.

For more information, see:

  • Guidance from Medicare in " Revisions to Consultation Services Payment Policy ," ( PDF ) in MLN Matters No. MM6740 Revised;
  • Q&A in the Dec. 31, 2009, Action
  •   " Evaluating Your 2010 Medicare Options ," a new, recorded Web seminar from TMA. Our in-house Medicare specialists will help you make an informed decision about your Medicare participation status for 2010 by (1) reviewing Medicare participation vs. nonparticipation options, (2) explaining the impact of changes in billing Medicare for consultation services, and (3) bringing you the latest information regarding Congress' action on the Sustainable Growth Rate formula and Medicare fee schedule. Register now to receive a link to the program via e-mail, then download the presentation whenever you're ready; and
  • For a tool to help you estimate the financial impact on your practice see  TMA's calculator tool


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