Proper coding of physician services is essential to efficient billing and the optimization of reimbursement from payers, including commercial and governmental entities.  The CPT^® codes issued by the American Medical Association (AMA) to describe physician procedures are supposed to be recognized as standards, but in practice they are not accepted equally by all payers.  One example is CPT codes in the range 99241-99255 that describe consultation services.  These are most often used by interventional radiologists, as described in our article Coding and Billing Considerations in Interventional Radiology.

In 2010, consultation codes ceased to be recognized by Medicare.  Instead, Medicare requires the use of either a new patient office visit code for outpatients (99201-99205) or an initial day of hospital care for inpatients (99221-99223).  Generally, payers other than Medicare have continued to accept the consultation codes, which carry a higher reimbursement due to the greater documentation and reporting requirements inherent in a consultation

United Healthcare recently announced that it would be phasing out payment for consultation codes 99241-99255 beginning in June 2019 under some of its provider contracts and by October 2019 for all providers.  The immediate change will be for contracts that contain rates based on a Medicare fee schedule from 2010 or later, as those fee schedules do not include the consultation codes.  United suggests that providers “modernize their fee schedules to bring them into alignment with CMS’s current Relative Value Methodology” before the October 1 date. 

As a result of this change, a coding reference table in our article is not as clear-cut today as it once was.  Rather than simply using the terms “Medicare” and “Non-Medicare”, we now must find out if a particular payer has adopted Medicare’s policies or maintains the AMA’s CPT coding definitions.

Evaluation and Management (E&M) visits for the purpose of deciding whether or not to perform a procedure are generally billable and payable if they occur outside of the Global Period (GP).  During the GP, all services related to the procedure are included as a component part of the surgical package, and therefore are not separately reimbursable.  However, for a procedure with a 90-day GP, considered to be a “major surgery”, an E&M service performed on the same day or preceding day for the purpose of deciding whether to perform the procedure may be separately reported and payable with the addition of Modifier -57 (Decision for Surgery).  United Healthcare has indicated that they are not altering their Global Days Policy at this time.  See our IR coding article for more on the Global Period, including a table showing which procedures are subject to this rule. 

This policy change by United might also modify the way documentation and reporting are handled.  When a consultation code is used, the request for consultation must be documented and the results of the consultation must be communicated by written report to the requesting physician according to the AMA guidelines.  Presumably, United and others following the Medicare policy will no longer require these two elements. 

United’s action is not surprising.  Commercial payers often adopt Medicare policies over time, particularly when doing so reduces their costs.  The challenge for radiology practices and their RCM vendors is to keep on top of frequent shifts in payer policies.  We at Healthcare Administrative Partners are constantly adapting to this changing environment, and we will keep you updated as a subscriber to this blog.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

Related Articles

How Radiologists Can Avoid Penalties Under the Medicare CDS/AUC Mandate

How Benchmarking Can Help Radiology Practices Evaluate Their Productivity

The Importance of Online Reputation Management for Radiologists