Consultations CPT CODES: 99241-99243, 99244-99255

The CMS concurs with American Medical Association “Current Procedural Terminology (CPT)” guidelines related to physician reporting of inpatient and outpatient consultation services 99241-99243, 99244-99255:


99241


Office consultation for a new or established patient, which requires these three key components:

• a problem focused history;

• a problem focused examination; and

• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.


99242



Office consultation for a new or established patient, which requires these three key components:

• an expanded problem focused history;

• an expanded problem focused examination; and

• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
The CMS will pay a consultation fee when the service is provided by a physician at the request of the patient’s attending physician when:

• All of the criteria for the use of a consultation code are met;

• The consultation is followed by treatment;

• The consultation is requested by members of the same group practice;

• The documentation for consultations has been met (written request from an appropriate source and a written report furnished the requesting physician);

• Pre-operative consultation for a new or established patient performed by any physician at the request of the surgeon; and

• A surgeon requests that another physician participate in post-operative care (provided that the physician did not perform a pre-operative consultation).

Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

HCPCS CODE - G0402 , G0367, G0368 AND G0344

 HCPCS Codes Used to Bill the IPPE

For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face-to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and report. If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only. The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366. The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367. The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Medicare will pay for a screening EKG only as part of the IPPE. HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.

Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).

The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face-to-face with the patient.

The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.

The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405


 Deductible and Coinsurance
. IPPE

The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.

The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. However, the applicable coinsurance continues to apply for the IPPE provided on or after January 1, 2009.

As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.



2. AWV

As a result of the ACA, effective January 1, 2011, the Medicare deductible and coinsurance for the AWV (HCPCS G0438 and G0439) are waived.



E. The EKG Component of the IPPE

The once-in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE.

Consultation Services versus Other Evaluation and Management (E/M) Visits

Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed.

In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual. T he principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” (Principal Physician of Record), in addition to the E/M code. Follow-up visits in the facility setting shall be billed as subsequent hospital care visits and subsequent nursing facility care visits.

In the CAH setting, those CAHs that use method II shall bill the appropriate new or established visit code for those physician and non-physician practitioners who have reassigned their billing rights, depending on the relationship status between the physician and patient.

In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall 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. All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer.

what is Split or shared services , consultation services

OTHER CONSIDERATIONS SPLIT/SHARED SERVICES

A split/shared service is an encounter where a physician and a NPP each personally perform a portion of an E/M visit. Below are the rules for reporting split/shared E/M services between physicians and NPPs:

** Office/clinic setting:

• For encounters with established patients that meet incident to requirements, report the using the physician’s National Provider Identifier (NPI); and

• For encounters that do not meet incident to requirements, report using the NPP’s NPI.

** Hospital inpatient, outpatient, and ED setting encounters shared between a physician and a NPP from the same group practice:

• When the physician provides any face-to-face portion of the encounter, report using either provider’s NPI; and

• When the physician does not provide a face-to-face encounter, report using the NPP’s NPI.


CONSULTATION SERVICES

Effective for services furnished on or after January 1, 2010, inpatient consultation codes (CPT codes 99251 – 99255) and office and other outpatient consultation codes (CPT codes 99241 – 99245) are no longer recognized by Medicare for Part B payment purposes. However, telehealth consultation codes (Healthcare Common Procedure Coding System G0406 – G0408 and G0425 – G0427) continue to be recognized for Medicare payment. Physicians and NPPs who furnish services that, prior to January1, 2010, would have been reported as CPT consultation codes should report the appropriate E/M visit code in order to bill for these services beginning January 1, 2010.