Consultation Code Update

UnitedHealthcare is aware of and has reviewed the Centers for Medicare and Medicaid Services’(CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultationcodes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and managementcode (99201-99215 or 99381-99397) rather than a consultation code for Medicare claimsdepending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code(99221-99223) for the first visit for Medicare claims. The admitting physician will addmodifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC)to differentiate between the admitting physician and other physicians providing care. Allphysicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initialnursing facility care” code (99304-99306) for the first visit for Medicare claims. The admittingphysician will add modifier AI to their initial nursing facility care service, allowing the MAC toidentify the physician as the admitting physician of record who is overseeing the patient’s care.

All physicians should use the subsequent nursing facility care codes (99307-99310) for theirfollow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010National Physician Fee Schedule. The status indicator of “I” is defined as:

“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and paymentfor, these services.

For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP®MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, theseplans will follow CMS regulations and implement the change, effective January 1, 2010. Thechange also includes the revalued relative-value units (RVUs) for E&M CPT codes and a newcoding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules fortheir fee schedules, AmeriChoice will be aligning with CMS and implement the change, effectiveJanuary 1, 2010. For all other Medicaid states, AmeriChoice will follow the UnitedHealthcarecommercial position and continue to pay for the consult codes, until directed by each state topursue other strategies.