What Payers Do Not Accept Consult Codes?

Medical billing uses specific codes to categorize and describe healthcare services, allowing for proper claim submission and reimbursement. Among these are the CPT consultation codes, such as 99241-99245 for outpatient services and 99251-99255 for inpatient services. These codes were originally designed to report services where a physician or other qualified healthcare professional provided an opinion or advice regarding a specific clinical problem at the request of another healthcare provider. This process facilitated inter-specialty collaboration and management of complex patient cases.

The Shift Away from Consult Codes

A significant change in medical billing occurred with the Centers for Medicare & Medicaid Services (CMS) policy, effective January 1, 2010. CMS eliminated separate payment for CPT consultation codes for Medicare beneficiaries.

CMS justified this change by citing perceived redundancy with existing Evaluation and Management (E/M) codes and a desire to reduce administrative burden. There was a belief that the work involved in consultations was not substantially different from other E/M services. CMS also aimed to address concerns about potential over-coding and misuse of consultation codes, noting studies that indicated some services billed as consultations did not meet the definition.

Major Payers and Their Policies

Many payers no longer accept dedicated consultation codes, following a trend initiated by federal programs. Providers must understand these policies to ensure accurate billing and avoid claim denials.

Medicare (CMS) explicitly stopped recognizing CPT consultation codes for payment as of January 1, 2010. Instead, providers should bill appropriate Evaluation and Management (E/M) codes that describe the service provided and the location of care.

Many state Medicaid programs have largely aligned their policies with Medicare regarding consultation codes. While specific state guidelines may vary, providers should verify the current policies with their state’s Medicaid program.

A significant number of private commercial insurance companies have also adopted similar policies. Insurers like Cigna and UnitedHealthcare, for example, no longer pay for CPT consultation codes, instructing providers to use appropriate non-consultative E/M codes instead. This widespread adoption of CMS’s policy by private payers creates a more uniform billing environment, though specific internal guidelines can still differ.

Appropriate Alternative Coding

When consultation codes are not accepted, healthcare providers must use alternative Evaluation and Management (E/M) codes to accurately reflect the services rendered. The choice of E/M code depends on the patient’s status and the setting of care.

For outpatient consultations, the service should generally be billed using new patient or established patient E/M codes. New patient codes (CPT codes 99202-99205) are appropriate if the patient has not received any professional services from the billing physician or another physician of the same specialty within the same group practice within the past three years. If the patient has received services within that three-year period, established patient codes (CPT codes 99212-99215) should be used.

For inpatient consultations, the services are typically reported using initial hospital inpatient care codes (CPT codes 99221-99223) or subsequent hospital care codes (CPT codes 99231-99233). Initial hospital care codes are used for the first inpatient encounter by the admitting physician or a consulting physician providing initial care for the patient’s hospital stay. Subsequent hospital care codes are used for follow-up visits after the initial inpatient encounter.

Regardless of the specific E/M code selected, documentation must fully support the chosen level of service. E/M code selection is based on either the medical decision making (MDM) complexity or the total time spent on the date of the encounter. A medically appropriate history and examination are also required, even if they are not the sole drivers for code selection.

Verifying Payer-Specific Guidelines

Healthcare providers and billing staff have an ongoing responsibility to verify specific coding and reimbursement policies with each payer. Payer guidelines can vary significantly and are subject to frequent changes.

Consulting official payer websites, provider manuals, and billing guides is a fundamental step in ensuring compliance. These resources provide detailed information on accepted codes, documentation requirements, and any unique billing nuances. When written policies are unclear or specific scenarios arise, direct contact with payer provider relations or billing support lines can provide necessary clarification.

Staying updated on payer policy changes is an ongoing process. Subscribing to payer newsletters, attending webinars, and regularly reviewing policy updates are proactive measures that help prevent billing errors. Failure to adhere to payer-specific guidelines can lead to claim denials. Incorrect coding can also result in delayed reimbursements, increased administrative burdens, and potential audits. Repeated errors may even lead to legal and compliance issues, including allegations of fraud and abuse.