Medicare Eliminates Consultation Codes

Both the inpatient and outpatient consultation codes can no longer be used for Medicare patients effective January 1, 2010, and all medical practices, regardless of specialty, are affected. The Centers for Medicare & Medicaid (CMS) published the final rule in the October 30, 2009, Federal Register.

“The elimination of consultation codes will impact practice revenue. Some practices will see a decrease, while others may see a slight increase,” says Robert Cox, senior health care consultant with Anesthesia Resources.

Existing codes to replace consultation codes

Old Codes New Codes
Outpatient consultation (99241-99245) New & established office (99201-99215)
Inpatient consultation (99251-99255) Initial inpatient hospital (99221-99223)
  Nursing facility (99304-99306)



For the initial visit code, the admitting physician will need to append a modifier “A1” to identify him or herself as the admitting physician, while other providers will just bill the appropriate initial visit code without a modifier. This will be a change from the previous guidelines, which only allowed one initial visit code per hospitalization.

The monetary value of the consult codes was higher than the codes they’ve been replaced by, which will have a negative affect for most practices. “Understanding the financial impact this change will have on your practice is critical,” Cox says. “It’s important to do a complete analysis of your consultation, office visit, and initial hospital/nursing facility production under the new terms.”

RVU adjustments

Work relative value units (RVUs) have been adjusted to make this change budgetary neutral for CMS. As such, the work RVUs for the new or established office/outpatient codes will be increased 6 percent. For the initial hospital and nursing facility codes, work RVUs will be increased by 0.3 percent.

Non-governmental payer coding conflicts possible

One potential problem practices will face is that non-governmental payers don’t have to follow Medicare’s rule change. Most non-governmental payers will eventually move toward Medicare rules but many already have fee schedules established, Cox says. This discrepancy can make extra work to ensure correct reimbursement. For example, BlueCross BlueShield of Louisiana will continue paying for consultation codes through June 30, 2010; it will be determined at a later date whether it will continue to do so beyond this date.

Further complications could occur if an initial claim is filed to a carrier that accepts the consultation codes, but Medicare is the secondary carrier and will not accept the original claim as coded. To maximize the capture of reimbursement, practices will need to review both charge tickets and processes to make sure these evaluation and management (E/M) visits are billed properly.

How we can help

Using the crosswalk created by CMS to estimate the code shift, Anesthesia Resources can help your practice determine the impact the elimination of consultation codes will have on revenue and work RVUs.

For more information on the coding changes and our tool, contact Robert Cox, senior health care consultant, at or 678-478-7866.

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