Reimbursement position for consultation codes (Commercial): Frequently asked questions

January 15, 2020

These frequently asked questions (FAQ) were developed to answer questions about the new AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (AmeriHealth) position regarding reimbursement for consultation codes as outlined in Claim Payment Policy #00.01.69: Consultation Services.

This document will be updated as additional information becomes available.

1. Why has AmeriHealth updated its reimbursement position for consultation codes?

At AmeriHealth, we are committed to our role as stewards of the health care dollars members and customers entrust us to manage. That means that every day we face the important challenge of balancing our commitment to competitively compensate physicians with our responsibility to keep health care affordable for our members.

In furtherance of these goals, effective April 15, 2020, AmeriHealth will align itself with the Centers for Medicare & Medicaid Services’ (CMS’s) standards by no longer recognizing Current Procedural Terminology (CPT®) consultation codes (99241 through 99245 and 99251 through 99255) as being eligible for reimbursement.

Instead, when providers see AmeriHealth commercial members, providers need to code patient evaluation and management (E&M) codes that represent where the visit occurred and identify the complexity of the visit performed.

The AmeriHealth decision to align with CMS’s standards regarding CPT consultation codes for its commercial members was based on the following:

  • Consultation codes 99241 through 99245 and 99251 through 99255 are not recognized for Medicare Part B payment by CMS.1
  • CMS’s rationale to pay consultation services differently is no longer supported because documentation requirements are now similar across all E&M services.2

2. What is the update to the AmeriHealth reimbursement position for consultation codes?

Effective April 15, 2020, when rendering services to AmeriHealth commercial members, AmeriHealth will no longer recognize the CPT consultation codes 99241 through 99245 and 99251 through 99255 as eligible for reimbursement.

Instead, providers need to code patient E&M visits with E&M codes that represent where the visit occurred and identify the complexity of the visit performed.

3. What is the effective date of this change?

Claim Payment Policy #00.01.69: Consultation Services, which implements the change, is effective for AmeriHealth claims on April 15, 2020.

4. Which providers will be affected by this update?

This update will apply to all professional providers who render services to AmeriHealth commercial members.

5. What other policies are affected by this position change?

This change to our reimbursement position for CPT consultation codes used to report consultation services also affects the following Claim Payment Policies, which were posted as Notifications (unless noted otherwise) on January 15, 2020, and will go into effect April 15, 2020:

  • #01.00.08: Preoperative Consultations Performed by Providers in Anesthesia Specialties: This policy will be archived, and anesthesia providers should report the CPT codes that represent the most appropriate level of E&M service.
  • #03.00.06: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The following CPT codes will be removed from this policy and will no longer be eligible for reimbursement:
    • 99241, 99242, 99243, 99244, and 99245
  • #00.06.02: Preventive Care Services: This update was addressed through News and Announcements on the Medical Policy Portal. The consultation codes will be removed from the pre-procedure consultation for colorectal cancer screening procedures. The providers should report the CPT codes that represent the most appropriate level of E&M service.
  • #00.10.42d: Telemedicine and Telehealth Services (AmeriHealth New Jersey): The following CPT consultation codes will be removed from this policy, and the most appropriate level of E&M service should be reported:
    • 99241, 99242, 99243, 99244, and 99245

6. How have providers been notified of the changes to these policies?

  • On January 15, 2020, these policy changes were announced to providers via
    • the Medical Policy Portal;
    • Partners in Health UpdateSM, our online provider newsletter;
    • AmeriHealth NaviNet® web portal (NaviNet Open) Plan Central in a message containing a summary of the changes to the policies and a link to the Medical Policy Portal.

7. Will these policy changes affect telehealth consultation codes G0425 through G0427?

AmeriHealth New Jersey

Yes. Claim Payment Policy #00.10.42d: Telemedicine and Telehealth Services (AmeriHealth New Jersey): The following CPT consultation codes will be removed from this policy, and the most appropriate level of E&M service should be reported:

  • 99241, 99242, 99243, 99244, and 99245

AmeriHealth Pennsylvania

No. The policy changes will only apply to consultation codes 99241 through 99245 and 99251 through 99255. AmeriHealth will continue to reimburse for CPT codes G0425 through G0427 as per Claim Payment Policy #00.10.41e: Telemedicine Services (AmeriHealth Pennsylvania).

8. Is there a direct crosswalk from consults to office/outpatient visits or consults to hospital or facility visits?

No. Keeping in line with CMS’s approach, AmeriHealth did not design a direct crosswalk. In the 2010 Medicare Physician Fee Schedule, CMS stated, “It is not necessary to develop any complicated coding crosswalk or guidelines for translating the consultation code requirements for purposes of applying the visit codes. The major effects of the provision may actually simplify coding because physicians will use the office and hospital visit codes in place of consultations and will not have to determine whether the requirements to bill a consultation are met.”

Providers should code patient E&M visits with E&M codes that represent where the visit occurred and identify the complexity of the visit performed.

9. What codes should physicians use for the first visit to the office?

For dates of service on or after April 15, 2020, if no other provider in the same specialty in the provider’s practice has provided any face-to-face service to the patient in the last three years, the provider should bill the New Patient Visit codes 99201 through 99205. If the patient has been seen within the last three years, the provider should bill the Established Patient Visit codes 99211 through 99215.

10. What codes should be used when seeing a patient for the first time in the hospital?

Providers should use the Initial Hospital Visit codes 99221 through 99223. Admitting physicians should add the AI modifier to the code.

11. What codes should be used when seeing a patient in the emergency room?

Providers should use the Emergency Department Visit codes 99281 through 99285.

12. What will happen if a provider continues to bill a consultation code on or after April 15, 2020?

Claims for E&M services billed on or after April 15, 2020, using consultation codes 99241 through 99245 or 99251 through 99255 will be denied. The applicable Provider Explanation of Benefits will contain a message indicating that the service is not eligible for reimbursement. To receive payment for the E&M service, the claim should be resubmitted using the appropriate E&M code as described in the policies.

Learn more

Please refer to the Medical Policy Portal to view the most recent version of these policies, as it will supersede the information in this FAQ.

If you cannot find the information you are looking for here and have further questions, please email us at CommercialConsultCodes@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email. 

1 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatt ersArticles/ downloads/mm6740.pdf

2 https://www.gpo.gov/fdsys/pkg/FR-2009-11-25/pdf/E9-26502.pdf

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