In 2010 the Centers for Medicare and Medicaid Services stopped paying for consultation codes. While it continued to recognize the concept of consults, it paid for them using new and established patient visit codes (99202 – 99215).
Beginning in 2021, new evaluation and management (E/M) guidelines became effective based on medical decision making (MDM) or time spent on the day of the encounter. See the 2021 Coding and Documentation Rules.
However, it seems that some third party-payers are beginning to follow Medicare’s “no consultation” rule.
| Payer | Commercial | Medicare Advantage |
|---|---|---|
| Aetna | Not covered | Not covered |
| CIGNA | Not covered | Not covered |
| Medicare | Not covered | Not covered |
| United Healthcare | Not covered | Not covered |
The above is not an exhaustive list and allergists should check with their commercial payers to determine whether they cover consultation codes. To ensure proper reimbursement, allergists should follow applicable, payer-specific policies governing the use and reporting of consultation codes (99241, 99242, 99243, 99244 and 99245).
Here’s how to crosswalk the consult codes to E/M codes based on MDM or time:
E/M based on MDM
Consults still use the 1995/1997 guidelines, while E/M visits use the new 2021 guidelines for MDM, so only use the level of MDM to select the appropriate new or established patient E/M code. The new guidelines for MDM don’t address the concept of the new patient or the new work up. New guidelines add more credit for data analysis and clarify that procedure risk is risk inherent to the procedure or patient.
E/M based on time
Codes 99202 – 99215 can be selected based on total practitioner time on the date of the encounter. Time must be documented in the patient’s chart and include a medical note for each activity to document what was done. Time includes face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professionals (clinical staff time is not included). A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. If an E/M code is selected based on time, it must also conform to the rules relating to time. (See CPT E/M Services).
The Advocacy Council: ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
