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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