Saturday, August 22, 2020

CPT code 99241, 99242, 99243, 99244, 99245

 

CPT code and Description

99241, Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making.


99242, Office consultation for a new or established patient, which requires these 3 components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making.


99243, Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity.


99244, Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.


99245, Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.


REIMBURSEMENT GUIDELINES Consultation Services


The American Medical Association (AMA) Current Procedural Terminology (CPT ®) book describes a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.


Oxford will consider a claim for a consultation service for reimbursement if the requesting physician or other qualified source is identified on the claim. If the requesting entity is not identified on the claim, the consultation service will be denied because it does not meet basic AMA requirements for reporting such a code.


Services initiated by a patient and/or family and not requested by a physician or other appropriate source should not be reported using CPT consultation codes 99241-99245 or 99251-99255 or HCPCS consultation codes G0406-G0408, G0425-G0427, G0508 or G0509 but may be reported using appropriate office visit, hospital care, home service or domiciliary/rest home care codes.


Note: AMA guidelines state that only one inpatient consultation (99251-99255) should be reported by a consultant per admission. Evaluation and Management (EM) services after the initial consultation during a single admission should be reported using non-consultation EM codes.


DEFINITIONS


Consultation Service: A type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

The following criteria also apply:

** A written or verbal request for consult must be made by an appropriate source

** The request must be documented in the patient’s medical record

** The consultant’s opinion must be documented in the patient’s medical record

** The consultant’s opinion must be communicated by written report to the requesting physician or other appropriate source



Payment Policy: Outpatient Consultations

Policy Overview
The American Medical Association’s (AMA) Current Procedural Terminology (CPT®) book describes a consultation as a type of evaluation and management (E&M) service provided at the request of another physicians or appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

Furthermore, if subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient’s condition(s), the appropriate E&M procedure code for the location of service should be reported.

The purpose of this policy is to outline how the health plan evaluates CPT consultation codes 99241-99245 and HCPS codes G0425-G0427 for reimbursement, particularly identifying those that should have been billed at the appropriate level of office visit, established patient or subsequent hospital care.

CMS no longer recognizes codes 99241-99245 and 99251-99255 for Medicare payment; therefore, providers should never bill these codes for Medicare members. Instead, (for Medicare members) providers should report the appropriate Evaluation and Management code payable under the fee schedule (including for visits that could be described by CPT consultations codes), that identifies where the visit occurred and the complexity of the visit performed.

Application
1. Professional
2. Outpatient Institutional Claims
3. Same member
4. Same Provider

Reimbursement

Claim lines that contain an outpatient consultation, when another outpatient consultation was billed by the same provider within six months, will be denied.

Services initiated by a parent and/or family and not requested by a physician or other appropriate source should not be reported using the CPT consultation codes 99241-99245 or HCPCS consultation codes G0425-G0427, but may be reported using appropriate office visit, hospital care, home service or domiciliary/rest home care codes. 

CPT guidelines state that only one outpatient consultation should be reported by a consultant per admission. E&M services after the initial consultation during a single admission should be reported using non consultation E&M codes.

Documentation Requirements

The following criteria apply:
** A written or verbal request for consult must be made by an appropriate source
** The request must be documented in the patient’s medical record
** The consultant’s opinion must be documented in the patient’s medical records
** The consultant’s opinion must be communicated by written report to the requesting physician or other appropriate source

Coding and Modifier Information

This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be allinclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. 
Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.



MEDICAL POLICY Consultation Services
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

DESCRIPTION
Consultations are unique evaluation and management services in which a provider has been asked for and is delivering an opinion. Patients seen in consultation may be either new patients or established patients. The intent of a consultation service is that a physician, qualified nurse practitioner, or other appropriate source is requesting advice, opinion, recommendation, suggestion, direction, or counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

The medical record documentation requires three key components following the American Medical Association (AMA) Current Procedural Terminology (CPT®) guidelines for evaluation and management services; history, physical and medical decision-making. Each component has different amounts of required information ranging from low to comprehensive levels.

The following criteria must be met and documented for the service to be considered a consultation:
** Documentation of the request for consultation from the referring provider
** The reason for the consult which must be medically reasonable and necessary
** A written report by the consultant which was provided back to the referring physician

Any provider may report a consultation service as long as they follow the consultation criteria, and the AMA/CPT coding guidelines for evaluation and management (E/M) services. If documentation is not been included or has been omitted, a lower level of service must be reported. Documentation must support not only the consultation
service, but also the level of service reported.

POLICY
Consultation services (99241-99245 and 99251-99255) are non-covered for Elite.
Consultation services (99241-99245 and 99251-99255) do not require prior authorization for HMO, PPO, Individual Marketplace, & Advantage

Elite
Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) no longer reimburses physicians for CPT consultation codes 99241-99245 or 99251-99255 and these codes will therefore not be recognized as reimbursed services for Elite members.

Procedures codes 99241-99245 (outpatient consultations) should be reported as 99201-99205 or 99211-99215 (outpatient office services), and procedure codes 99251-99255 (inpatient consultations) should be reported as 99231-99233 (inpatient hospital services). While these services may be valid (AMA/CPT) and reportable (HIPPA) codes, it does not make them reimbursable. The AMA/CPT does not establish reimbursement guidelines; only the codes by which reimbursement is performed.

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