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Reimbursement position for consultation codes (Medicare Advantage): Frequently asked questions

May 3, 2018


This FAQ was revised on June 4, 2018.


These frequently asked questions (FAQ) were developed to answer questions about Independence Blue Cross?s (Independence) new position regarding reimbursement for consultation codes as outlined in Medicare Advantage policy #MA00.049: Consultation Services.

Note: This document will be updated as additional information becomes available.

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

Independence is committed to identifying solutions that will help stem the tide of escalating health care costs and help ensure members and customers receive high-quality care in the safest, most cost-appropriate settings. In furtherance of these goals, effective August 1, 2018, Independence 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 Independence Medicare Advantage HMO and PPO 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.

Independence?s decision to align with CMS?s standards regarding CPT consultation codes for its Medicare Advantage 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 Independence?s reimbursement position for consultation codes?

Effective August 1, 2018, when rendering services to Independence Medicare Advantage members, Independence 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?

Medicare Advantage policy #MA00.049: Consultation Services, which implements the change, is effective for Independence claims on August 1, 2018.

4. Which providers will be impacted by this update?

This update will apply to all professional providers who render services to Independence Medicare Advantage 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 our Medicare Advantage policies on preoperative anesthesia consultations and Modifier 25, as detailed below:

  • #MA01.002: Preoperative Consultations Performed by Providers in Anesthesia Specialties: Effective August 1, 2018, this policy will be archived, and anesthesia providers should report the CPT codes representing the most appropriate level of E&M service.
  • #MA03.003d: 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: Effective August 1, 2018, the following CPT codes will be removed and will no longer be eligible for reimbursement:
    • ? 99241, 99242, 99243, 99244, 99245

6. How have providers been notified of the changes to these policies? (Revised 6/4/2018)

On May 3, 2018, tthese policy changes were announced to providers via:

  • Independence Medical Policy Portal.
  • Partners in Health UpdateSM, our online provider newsletter;
  • Independence NaviNet® Plan Central in a message containing a summary of the changes to the medical policy and a link to the Medical Policy Portal.

A reminder article was published on June 4, 2018, via Partners in Health Update.

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

No. The policy changes will only apply to consultation codes 99241 through 99245 and 99251 through 99255. Independence will continue to reimburse for CPT codes G0425 through G0427 as per its current contracted fee schedule.

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, Independence 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 August 1, 2018, 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 August 1, 2018?

Claims for E&M services billed on or after August 1, 2018, 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.

For more information

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 consultcodes@ibx.com. Be sure to include your name, contact number, and provider ID number in your email.

You can download a PDF of this FAQ here.

1https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Net work-MLN/MLNMattersArticles/ downloads/mm6740.pdf

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

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