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ACRO ALERT  Medicare Eliminates Payment for Consultation Codes
published 12/2/2009
Effective January 1, 2010, Medicare will no longer pay for services billed using consultation CPT codes, except for telehealth services.  This change was made in a budget neutral manner, such that Medicare increased the payments for new patient visits.  

Starting January 1, office visits should be billed using either a new patient visit code (99201-99205) if new patient criteria are met; if not, use an established patient visit code (99211-99215).  Inpatient consultations should be billed as initial daily care visits (99221-99223) with subsequent visits billed as subsequent daily care (99231-99233). 

CMS has made this change to address the confusion about appropriate billing for consultation services and transfer of care issues.  Previously, a consultation could be billed only when the consulting physician had not assumed responsibility for the patient's care and was strictly providing his/her advice to the treating physician.  CMS found that more often than not, consultation codes were billing inappropriately as the "consulting" physician had assumed some or all of the patient care responsibilities.  The elimination of payment for consultation codes should yield one positive result in that CMS audits should no longer identify inappropriate billing of consultation services as a frequent problem requiring repayment to Medicare.  As CMS notes "the major effects of the provision may actually simplify coding because physicians will use the office and hospital visit codes in place of consultations and will not have to determine whether the requirements to bill a consult are met." 

Each practice should evaluate the effects of this change based on the practice's unique mix of services provided.   However, radiation oncologists will likely experience a decline in evaluation and management service revenue as a result of this new CMS policy. 

Please note that the CPT codes for consultation services will remain in the CPT book.  However, no payment will be made by Medicare when services are billed using these codes.   It is unclear whether additional payers will follow Medicare's policy and eliminate payment for consultation codes. 

Three new telehealth G codes are payable when used to bill telehealth services for inpatients.  The codes are:

G0425 - Initial inpatient telehealth consultation, typically 30 minutes communicating with the patient via telehealth.

G0426 - Initial inpatient telehealth consultation, typically 50 minutes communicating with the patient via telehealth.

G0427 - Initial inpatient telehealth consultation, typically 70 minutes or more communicating with the patient via telehealth.


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