Pediatric Coding Alert

Question: I'm hearing that consultation codes (99241-99255) will go away in 2010. How will this affect pediatrics?

Pennsylvania Subscriber

Answer: CMS has proposed ending coverage of consultation codes (99241-99255) to increase payments for primary care services. The AMA plans on maintaining the codes at least for CPT 2010. For Medicare and private payers that adopt Medicare's consultation coverage change, you would use E/M codes (99201-99215 for office visits or 99221-99223 for hospital care), rather than consultation codes (99241-99245 for outpatient consults and 99251-99255 for inpatient consults).

The proposed rule suggests redistributing the savings that would result from invalidating consultation codes into payments for E/M services, such as office visits (99201- 99215, Office or other outpatient visit ...) and initial hospital care (99221-99223). CMS would still leave the values for 99241-99245 in the Medicare Physician Fee Schedule so that private payers can see the codes' relative value units agreed upon by the RBRVS Update Committee (RUC) and CMS.

Impact: You'll have to keep track of what insurers accept 99241-99245 (Office consultation ...). Private payers that base their fees on Medicare may drop payment for consult codes, too, forcing you to use visit codes, rather than traditionally higher-paying consult codes. For insurers that have their own fee schedules, you may still use the consult codes.

Stay tuned to Pediatric Coding Alert to find out how the proposed rule pans out. The American Academy of Pediatrics (AAP) anticipates that if enacted the consult pay elimination could benefit general pediatricians who might see a payment increase from increased frequently used office visit codes. Pediatric specialists, however, who tend to bill more consultations, could see declines in revenue.

For more on the consultation code proposal, see page 33 of the July 13th Federal Register (http://edocket.access.gpo.gov/2009/pdf/E9-15835.pdf). To read the press release, visit  www.cms.hhs.gov/apps/media/press/release.asp?Counter=3469.