Wiki Consultation Coding clarification

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hstrasko_rn@atlanticlegalnurseconsultants.com

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Hi to all. I am aware that Medicare deleted the Consultation Codes: 99241-99245 for Office/Other Out Pt. Consultations. Many Offices are using the New
Pt. codes instead for their Medicare Pts., 99203-99205.
My question is are you still using the Consultation codes: 99241-99245 for the rest of the other Insurances? i.e. Blue Shields, TPA Insurances, Commercial Insurances, etc.
(*Another Office has deleted all of their Consultation codes all together since Medicare stopped using them a few yrs. back & do not charge any Consultation codes at all anymore. This just seems so strange to me.)
Thank you for your help. H.Strasko, RN, CPC ;)
 
Use of those Consultation codes is payer specific. Some commercial payers still accept them, but others do not, and you almost have to query the payers individually.

We are using the consultation codes for some Anthem, Cigna, United Healthcare, Aetna and several other regional payers.
 

Hello Pam,
Thank you very much for your response. As a matter of fact, the client
that needs to be billed is an Anthem Insured patient. Small world. Thank
you. The office had billed for a regular Ophthalmology O.V. Estab. Pt. even though it was clearly a consultation & Pt. had never seen Dr. before.
I appreciate you taking the time out of your busy day to answer my question. I figured it would depend on the Insurance carrier. I just did a computer or (Encoder type search) & this code does still exist.
(Sometimes I feel like I'm playing the old telephone game when I was a little girl.)
Have a good day. ;) H.Strasko RN, CPC
 
hstrasko_rn@atlanticlegalnurseconsultants.com said:

Hello Pam,
Thank you very much for your response. As a matter of fact, the client
that needs to be billed is an Anthem Insured patient. Small world. Thank
you. The office had billed for a regular Ophthalmology O.V. Estab. Pt. even though it was clearly a consultation & Pt. had never seen Dr. before.
I appreciate you taking the time out of your busy day to answer my question. I figured it would depend on the Insurance carrier. I just did a computer or (Encoder type search) & this code does still exist.
(Sometimes I feel like I'm playing the old telephone game when I was a little girl.)
Have a good day. ;) H.Strasko RN, CPC
Click to expand...

I'm curious as to why you would bill an established O/V for a new patient? Also, UHC, Oxford, UMR, Local 1199, US Family, Nippon Life and Americhoice is on our list of insurances that no longer recognize the consultation codes.
 
You cannot bill a consult for Medicare or any Medicare replacement insurance as they follow Medicare policy on this. You would need to check if the patient was new or established to know which e/m to bill. If the patient is does not have a Medicare replacement policy you can usually bill a consult but the note would have to state they are there for a consult.
 
Hello to all. This patient is NOT a Medicare patient. The patient has Anthem insurance. The Medicare bulletin is an older one dating back to @ 2011 and had provisions on the bottom how to bill for a "consultation" with patients seeing a Dr for the 1st time. It recommended using the New E/M codes 99203-99205 which many offices are doing. When one stops and reflects for a moment. Yes, the patient is technically seeing the New Dr. or Consultant who is new to them for the 1st time. This would also include the (3) yr. provision in regards to whether or not to charge a patient the new O.V. code. Remember, all of these bulletins must be kept in a ringed binder should a Medicare Representative stop by your Office as part of an audit.
Thank you to all who have assisted me with the names of carriers who are still accepting the Consultation code as of now.
Helen Strasko, RN, CLNC, CPC, (Certified Legal Nurse Consultant is what CLNC stands for to those who were inquiring.) I truly appreciate everyone help. ;)
 
Pt. is only established with primary opthamologist. He has never seen the specialist opthamologist. They all have their own cost center charge codes. He is not established with this Dr. yet. Technically, he's only established with the one Dr. Therefore, according to the Medicare proviso and their bulletin, he is new to this Dr. and visa versa. Therefore, the patient would also meet the (3) yr. provision. He's never been seen by this specialist. Medicare has suggested since they took away the consultation code for MEDICARE & MEDICAID PATIENTS ONLY! To use the E/M code for new patients. Drs. typically perform a more in depth H & P with these patients and that's what these codes are for. (99203-99205 in particular.) Of course if a more focused yet lower E/M is utilized, then charge for that code. This bulletin is from @2011. H.Strasko
 
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