Notification

Consultation Services


Notification Issue Date: 05/03/2018

Effective August 1, 2018, Independence will update its reimbursement position on the Current Procedural Terminology (CPT®) codes used to report consultation services provided to Independence’s Medicare Advantage HMO and PPO members. Based on a review of the Centers for Medicare & Medicaid Services (CMS) standards, Independence will no longer recognize the following CPT consultation codes as eligible for reimbursement:

  • 99241, 99251, 99242, 99252, 99243, 99253, 99244, 99254, 99245, 99255

When rendering services to Independence Medicare Advantage HMO and PPO members, all providers should report the code(s) representing the appropriate level of evaluation and management (E&M) service in lieu of consultation codes.

This change to our reimbursement position for CPT consultation codes used to report consultation services also affects our Medicare Advantage policies on preoperative anesthesia consultations and Modifier 25 as outlined below.

Changes to the following Medicare Advantage policies will also go into effect August 1, 2018:
  • #MA01.002: Preoperative Consultations Performed by Providers in Anesthesia Specialties: This policy will be archived, and anesthesia providers should report the CPT codes that represent the most appropriate level of E&M service.
  • #MA03.003d: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The following CPT codes will be removed from this policy and will no longer be eligible for reimbursement: 99241, 99242, 99243, 99244, and 99245



Medicare Advantage Policy

Title:Consultation Services
Policy #:MA00.049

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Current Procedural Terminology (CPT) consultation codes are not eligible for reimbursement. The appropriate level of Evaluation and Management (E&M) service should be reported.

For a list of CPT consultation codes, refer to the Coding Table in this policy.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

Description

A consultation is a type of service provided by a physician or other qualified healthcare professional whose opinion or advice regarding the evaluation and management (E/M) of a specific clinical problem is requested by another physician or other qualified healthcare professional.
References

Centers for Medicare & Medicaid Services (CMS). MLN Matters® Number: MM6740. Revisions to Consultation Services Payment Policy. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6740.pdf



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA00.049
08/01/2018This is a new policy that will be effective 08/01/2018. This policy has been created to indicate that Current Procedural Terminology (CPT) consultation codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255 are not eligible for reimbursement. The appropriate level of evaluation and management (E&M) service should be reported.




Version Effective Date: 08/01/2018
Version Issued Date: 08/01/2018
Version Reissued Date: N/A