Clarifying consultation code confusion

A: I can see why you are confused. Consultation codes (99241–99253) are listed in the 2010 Current Procedural Terminology (CPT) code book, which means that the American Medical Association (AMA), the entity that publishes the book, still recognizes them. The AMA guidelines are applicable to all payers, including commercial carriers. Here's the catch, however: although the Centers for Medicare and Medicaid Services (CMS) will recognize the consultation codes, it is not reimbursing for them as of January 1, 2010. Here are the changes:

Realistically, many specialists know that they will be assuming the care of a patient before the first visit. For example, a primary care physician examines a patient and orders an x-ray that determines that the patient's leg is broken. The doctor then refers the patient to an orthopedic specialist for treatment of the break. In this situation, the orthopedic specialist knows the patient's condition before the referral and knows he or she will be assuming care for that condition before the first visit. Therefore, the orthopedic specialist should bill a new patient code (not a consultation).

Unfortunately, cross-walking consultations to new or established codes will not be easy. You will need to know the key requirements for each code and verify the correct place of service. One suggestion is that you should code the service based on CPT requirements, then modify the code selection and reporting based on payer requirements, if needed. Remember, a level 3 new patient code does not equal a level 3 established patient code.

The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Have a coding or managed care question for our experts? Send it to meletters@advanstar.com
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