Otolaryngology Coding Alert

Question: I have a denial for 99253 from Anthem Senior Advantage stating that this code is no longer reimbursed by CMS. What code should I report instead?

Ohio Subscriber

Answer: If you are billing the service to Medicare, you won't be paid because Medicare has stopped recognizing CPT^® codes for consultation services in 2010. The affected codes were:

• 99241-99245 (Office consultation for a new or established patient, which requires these 3 key components ...)
• 99251-99255 (Inpatient consultation for a new or established patient, which requires these 3 key components ...).

Instead of reporting these codes to Medicare, now you bill with initial hospital care codes (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components ...) or subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...) as per day of services of admission.

Remember, however, that some private payers still accept the consultation codes. Verify each payer's policies before submitting your claim.

New or established: According to CPT^® guidelines, a patient usually is considered to be "established" if the same physician, any physician in the group practice, or any physician of the same specialty who is billing under the same group number has seen the patient for a face–to–face service within the past 36 months.