Billing consult code to Medicare - New updated rule

New Medicare Coding for Consultation Services

As of January 1, 2010, Medicare no longer recognizes CPT procedure codes for consultation services (CPT codes 99241- 99245 and 99251-99255). This change represents a very significant change in Medicare payment policy; however, as of now, the change is for Medicare only. Commercial payors have not yet adopted similar guidelines when it comes to consultation services and providers should continue to use the consultation codes for all non-Medicare payors. Surgeons should check with each individual commercial  payor to determine if that payor is continuing to accept the 99241-99245 and 99251-99255.


When billing Medicare, providers will be required to use other Evaluation and Management (E/M) codes when they provide services that were previously coded as consultations. Specifically, for office or outpatient  consultations, Medicare will not recognize codes 99241- 99245, but will, instead, require providers to bill these services as new (99201- 99205) or established office/outpatient (99211-99215) visits. For inpatient consultations, Medicare will not recognize codes 99251-99255 but will instead require providers to bill these services as initial inpatient patient visits (99221-99223). For inpatient initial hospital visits, the admitting physician will have to append a modifier, AI, in order for the consulting physician to get reimbursed. For Emergency Department consultations, which would have formerly been coded as outpatient consultations (99241-99245), will now be billed as Emergency Department visits (99281- 99285).


Medicaid update

The Centers for Medicare and Medicaid Services (“CMS”) has eliminated the use of all inpatient and office/outpatient consultation codes for dates of service on or after January 1, 2010. Inpatient codes 99251 to 99255 and outpatient/office codes 99241 to 99245 will no longer be accepted by CMS. As a result, medical providers who are billing under the Tennessee Medical Fee Schedule, which is largely based on Medicare’s reimbursement formula, will need to discontinue the use of inpatient codes 99251 to 99255 and outpatient/office codes 99241 to 99245. Instead, medical providers should bill, as applicable:

• Initial inpatient hospital care: 99221 to 99223
• Subsequent hospital care: 99231 to 99233
• Initial nursing facility care: 99304 to 99306
• New patient office visit: 99201 to 99205

• Established patient office visit: 99211 to 99215