Billing Medicare for Consultations Codes?

Medicare is no longer accepting office consultations codes (99241-99245) or hospital consultations codes (99251-99255), as of January 1, 2010. Why? Well, the Office of Inspector General estimates that approximately 75% of consultations billed to Medicare were incorrect;specifically, 47% of consultation billing to Medicare involved wrong type or level of service, 19% did not meet definition of consult and 9% lacked appropriate documentation. Also, OIG audits have uncovered that in 2006 overpayments for consultations by the Medicare program amounted to approximately $1.1 billion in 2001.

Instead, “consultation” services will fall under the following codes, depending on the services rendered:
Office Visits ( New patient or established)
99201-99205 or 99212 - 99215

Initial Hospital Visits ( Admit or subsequent care)
99221- 99223 with modifier (AI) or 99231-99233
**Note: the AI modifier = admitting provider only

I’ve asked our friend Louis at E Central Medical Management to provide suggestions for practices in response to the Medicare changes and he offered:

1. In addition to being educated about the new changes, all practices should adopt new charge slips or superbills that reflect the Medicare changes. A professional should be consulted to help the practice accomplish this because all future billing will be based on the new charge slips and/or superbills and they must be correct.

2. Because the old codes do not simply translate over to the newly designated codes (i.e., a 99254 doesn’t necessarily equal a 99222), practice administrative staff or even a professional biller or coder should not select new code designations without the input of the doctor performing those services.

3. Be sure that all codes are substantiated by documentation because where coding changes happen, audits are bound to follow.

Contact Louis with any questions regarding the new Medicare codes and for assistance with creating new charge slips and/or superbills at 718.525.8567 or E Central Medical Management regularly provides consultation services for healthcare practitioners for all practice billing issues.

Note: the above change only applies to Medicare for now. All practices should continue to bill commercial carriers for consults, medical clearances and follow consultation documentation guidelines for both commercial payors and Medicare.