Wiki Why use consult code when E/M codes pay more?

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cardiocoder

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If a patient is a commercial health plan like anthem blue cross, why would physician choose to bill as consultation code (99241-99245) for a new office visit when you can bill as a E/M code (99201-99205) and get paid more?

Same goes for inpatient hospital consults (99251-99255) where the 99255 gets paid less than than a 99223?
 
Because it's not supposed to be entirely about the money. According to the federal guidelines, we are expected to bill the code that represents the very service that was provided. If a provider is asked to consult, regardless of the reimbursement, that is what you are expected to bill, unless your payer (with whom you are contracted) requires otherwise.

Don't get into the habit of thinking only of reimbursement. Think compliance first. Remember your AAPC Code of Ethics.
 
but if medicare switched to only E/M code, why would anyone use the older consult codes for commercial carriers if they also have E/M codes?
 
cardiocoder said:
can u clarify why u would choose consult code over e/m code?
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As stated in previous post, CPT selection should be based on the service provided/documentation, not reimburesment. Even though Medicare, and most other government payers, no longer allow consults, most commercial payers do. If a consult is documented, and the payer allows consults, that is what should be coded and billed.

Other point to keep in mind....some payers have a higher reimbursement for consult codes. This, of course, will vary by provider/payer contracts.
 
Consult codes used to be for something the treating doctor could not treat or determine what was wrong. The treating requested a specialist to examine the patient and figure out a plan of care. Ex: pediatrician has newborn with slow weight gain, stomach pain, and change in formula did not resolve the problem. He referred the baby to a pedi gastro doctor and this specialist found H. Pilori. Pediatrician then took back over the care. Most consults in our area to pay more due to the complexity and higher MDM.
 
mhstrauss said:
As stated in previous post, CPT selection should be based on the service provided/documentation, not reimburesment. Even though Medicare, and most other government payers, no longer allow consults, most commercial payers do. If a consult is documented, and the payer allows consults, that is what should be coded and billed.

Other point to keep in mind....some payers have a higher reimbursement for consult codes. This, of course, will vary by provider/payer contracts.
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how is documentation for a 99203/99204 (E/M) different from a 99243/99244 (Consult)? It seems that cigna and aetna pays more for 99244/99243 than 99203/99204. On the other hand, blue cross pays more for 99204 than 99244

For hospitalized patinets, 99223 (E/M) pays more than 99255 (consult) but 99222 (E/M) pays less than 99244. Any links to where it distinguishes documentation between 999255 and 99223 if a specialists (i.e. GI, cardiology, etc) is called by a hospitalist?
 
cardiocoder said:
how is documentation for a 99203/99204 (E/M) different from a 99243/99244 (Consult)? It seems that cigna and aetna pays more for 99244/99243 than 99203/99204. On the other hand, blue cross pays more for 99204 than 99244

For hospitalized patinets, 99223 (E/M) pays more than 99255 (consult) but 99222 (E/M) pays less than 99244. Any links to where it distinguishes documentation between 999255 and 99223 if a specialists (i.e. GI, cardiology, etc) is called by a hospitalist?
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The difference in documentation from a 99243/99244 and a 99203/99204 really comes down to the intention of the referring doctor. The levels of the HPI, exam, MDM are the same. If the referring MD requested a consult, and your doctor fulfilled the requirements of the consult, then that is what should be billed (as long as payer still allows this). If the referring MD simply documented a "referral" or transfer of care, then your doc would bill a New patient visit (or established if already a patient with you). This confusion is probably one of the reasons Medicare stopped accepting consult charges. From what I've read, a lot of providers were not using the consult charges appopriately, and since medicare paid more for consults, that lead to abuse and overpayments.
 
The reimbursement for the various E&M codes is based on the contract your provider has with the commercial insurances. I find it odd, that a payer would allow more for an office visit code as opposed to a consult code. I would also check with your contracts to make sure you are being reimbursed accordingly.
 
agreed with the last poster. what you charge is up to your practice. what you are reimbursed is based on contracts with insurance. so if your consult codes are a lesser charge than your, say, Office visit codes, then that is an issue with whoever is in charge of setting your rates.

your practice can charge whatever it wants to insurance companies, but it is the contract between your practice and insurance that really matters.

generally, a NPT consult would normally be a higher charge than a NPT Office E/M of the same level, because a consult is usually requested because the consulting MD has more expertise in the pertinent area.

now, since CMS doesn't pay for consults anymore, my old practice(and I'm sure everyone else) had to swap over to Outpatient E/M codes for office and then initial admit codes for INPT.
 
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