So Now How Do I Bill Medicare for Consultations?

 Medicare no longer pays physicians for consultations using the CPT consultation codes (99241-99244 for office or other outpatient consults and 99251-99255 for inpatient consultations). Instead, the Centers for Medicare & Medicaid Services (CMS) instructed physicians to bill using the new or established patient codes. Here is a Q-and-A to help you make the transition. Read more frequently asked questions on the TMA Web site.

Q.  Is CMS going to crosswalk the now-defunct CPT consultation codes to the appropriate E&M codes?

A.  No, it is up to you to bill the most appropriate evaluation and management (E&M) code available for a service you previously would have billed using a CPT consultation code. For example, for services that would have fallen under inpatient consultation CPT codes, CMS suggests you could bill the initial hospital care service codes 99221 through 99223 (or the initial nursing facility care CPT codes) if they describe the level of service you provided.

Q.  Fine, but what if the service that I would have billed under the old CPT inpatient consultation codes 99251 or 99252, which were lowest-level of the inpatient consultation codes, doesn't meet the minimum key component work and/or medical necessity requirements for the initial hospital care codes? For example, one element of inpatient consultation CPT code 99251 required "a problem-focused history," and code 99252 required "an expanded problem-focused history." In contrast, initial hospital care CPT code 99221 requires "a detailed or comprehensive history." It is not a good match.

A.  Look at other code descriptions to find your best match. In this case, consider subsequent hospital care CPT codes 99231 and 99232, which require, respectively, "a problem-focused interval history" and "an expanded problem-focused interval history." One of these codes might describe the service you provided and would have billed under one of the old consultation codes.

Q.  But won't that raise some kind of red flag - if I use a subsequent hospital care CPT code to report my first E&M service to a patient during a hospital stay?

A. CMS has instructed Medicare contractors to not find fault with physicians who report a subsequent hospital care CPT code when the medical record demonstrates that you met the work and medical necessity requirements for that code, even if it is for your first E&M service to a patient during a hospital stay.

CMS has alerted TrailBlazer audit staff as well as Medicare Recovery Audit Contractors that it expects physicians may - appropriately - bill more E&M codes for initial hospital care in place of billing inpatient CPT consultation codes..

Q.  How should I bill for E&M services that are not described by any of the CPT E&M codes that Medicare pays.

A.  Report those services reported with CPT code 99499 (Unlisted evaluation and management service). Reporting CPT code 99499 requires that you submit medical records, and TrailBlazer perform a manual medical review of the claim before paying it. CMS expects reporting of this E&M code to be unusual.




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