Change is coming to United Health Care

The Advocacy Council has learned that beginning October 1, 2017, United Health Care (UHC) will stop paying for physician visits billed under certain inpatient and outpatient consultation codes (CPT codes 99241-99245 and 99251-99255). According to the July UHC Network Bulletin (page 28). services previously reported with consultation codes 99241-99245 and 99251-99255 should now be reported with the appropriate evaluation and management (E/M) procedure code, which describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care. This will make UHC’s policy the same as Medicare’s which stopped paying for consultation codes in 2010.

Instead, physicians should use the regular office or inpatient visit codes that best describe the service. According to the June UHC Network Bulletin, “at the time of the original CMS decision to no longer recognize these consultation services procedure codes, United Health Care began pursuit of data analysis and trending to better understand the use of consultation services codes as reported in the treatment of our commercial members. Similar to CMS’ findings, our extensive data analysis has revealed misuse of consultation services codes for this population.”

UHC will deny claims submitted with the consultation codes that are billed after September 30, 2017 but will allow physicians to resubmit using the correct code.

The consultation codes have historically been used to describe services provided at the request of another physician in situations where the consulting physician does not take over care of the patient. We are not aware of any other private payers that have changed their policies related to these codes, but will continue to monitor the situation.

Advocacy Issue: 
Billing, Coding & Payments