In 2011, the Centers for Medicare & Medicaid Services (CMS) terminated their use of consultation codes. They created a crosswalk system to transition providers away from using these eliminated codes. Office/outpatient Evaluation & Management (E/M) codes 99211-99205 replaced consult codes 99241-99245. Initial hospital care codes 99221-99205 replaced 99251-99255.
This shift resulted in lower reimbursement because the Relative Value Units (RVUs) for non-consult codes are significantly lower than those of the eliminated consult codes. Other payers still accepted the consult codes, causing confusion over inpatient consult codes being replaced with initial hospital care codes. The new AI (principal physician of record) modifier created confusion as well. The AI modifier was to be appended by admitting physicians so that specialists doing consultations could report initial hospital care codes on the same day. However, many didn’t use the modifier resulting in denials for duplicate services.
Training was provided to fix these issues, but physicians still had a decision to make. They had to decide if they would continue documenting the additional information required for consult codes that other E/M codes don’t need. This additional information includes: requesting provider, reason for consult, report of results, and recommended treatment. Some providers liked these details because they help to differentiate consult and transfer of care situations. Others preferred to omit these extra details because they viewed them as more work for less reimbursement in the end.
UnitedHealth announced in March of 2019 that they would be updating fee schedules to align more with Medicare. They will be eliminating the consult codes in congruence with the CMS. Cigna announced the same in July of 2019 that they would be implementing a new reimbursement policy. Their deadline is October 19, 2019, after which CPT consultation codes will not be valid. Though claims rejected for this reason may be resubmitted with the appropriate non-consultation E/M code. This update for both UnitedHealth and Cigna reflect their private plans. Any Medicare Advantage plans eliminated consult codes back in 2011. This is a big change for practices used to commercial insurances.
For more information on this transition, please visit: