CMS Release Guidance on Billing for Consultation Codes
December 16, 2009
The Centers for Medicare and Medicaid Services released their claims processing transmittal 
on billing for the consultation codes, which were eliminated from the Medicare Physician Fee Schedule in CMS' final rule October 30.
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part A/B payment. Physicians should code patient evaluation and management visit with E/M codes that represent where the visit occurred and that identify the complexity of the visit performed.
To ensure proper coding, rheumatology practices should bill the appropriate E/M level to replace the consultation codes for claims accordingly as outlined below:
Outpatient Services:
Physicians and other qualified non-physicians practitioners are to bill the appropriate new—or established outpatient visit codes—in the office and other outpatient settings using CPT codes 99201-99205 or 99211- 99215.
Inpatient Services:
Inpatient physicians and other non-physician practitioners who perform an initial evaluation and management should bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur in a single day.
To define the admitting physician, CMS has created the "AI" modifier, which is to be used by the admitting or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care. The "AI" modifier is defined as "Principal Physician of Record."
The admitting or attending physician must append modifier "-AI" in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient should only bill the E/M code for the complexity level performed.
Note: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. CMS as indicated that it is not necessary to reject claims that include the "-AI" modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes).
Follow-up visits in the facility setting should be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians should bill the available code that most appropriately describes the level of the services provided.
Below are the codes for 2009-2010:
2009 |
2010 |
2009 |
2010 |
|
|---|---|---|---|---|
E/M Levels |
OP Consult |
New Patient |
Inpatient Consult |
Initial Inpatient |
Level 1 |
99241 |
99201 |
99251 |
99221 |
Level 2 |
99242 |
99202 |
99252 |
99222 |
Level 3 |
99243 |
99203 |
99253 |
99223 |
Level 4 |
99244 |
99304 |
99254 |
|
Level 5 |
99245 |
99205 |
99255 |
|
For additional information, or if you have questions about coding and billing, contact the Socioeconomic staff at (404) 633-3777.
