2009-12-17

Effective January 1, 2010, consultation codes are no longer recognized for Medicare Part B Fee for Service payment. The Center for Medicare & Medicaid Services (CMS) has provided instructions on how to code for the services that were previously identified as consultations. Physicians must code patient evaluation and management (E/M) visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. All E/M services must follow the E/M documentation guidelines. In the inpatient hospital setting and the nursing facility setting, all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306). Modifier "-AI," defined as "Principal Physician of Record," must be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record must append modifier "-AI" in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient must bill only the E/M code for the complexity level performed.

In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners must use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.

Initial review of the documentation has raised several questions, which ASH is working to answer. A more detailed analysis will be following within days. To submit questions, please contact Carol Schwartz.

Multiple medical societies have asked CMS to delay the elimination of consult codes. CMS staff have said that the agency is considering the request, but decided to proceed with the transmittal to instruct physicians on how to code in case the final decision was to proceed with implementation. In addition, Senator Arlen Specter (D-PA) has filed an amendment to the Senate health reform bill prohibiting the elimination of the consult codes until January 1, 2011. The amendment requires the Secretary of HHS to work with the CPT Editorial Panel to modify existing or create new consult codes to accurately reflect the value of these services. Since the health reform bills will not be enacted before the first of the year, the elimination of the consult codes likely will proceed unless CMS changes its policy. ASH encourages you to contact your Senator through the ASH Advocacy Center to support Specter Amendment Number 3163.

back to top