CPT CODE 99243 - Office visit consultation level 3

CPT CODE and description

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. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

average fee amount - $120 - $130

99243 Office consultation for a new or established patient, which requires these three key components:

• A detailed history

• A detailed examination

• Medical decision making of low complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

CPT Typical Time

99243 45

A consultation occurs when a treating physician seeks an opinion from another physician regarding a patient’s diagnosis or treatment and meets the CPT® requirements for a consultation. An independent medical exam (IME) occurs

when a physician is requested to evaluate a patient by any party or party’s representative and is billed in accordance with section 18-6(G).

 Outpatient Consultation RVUs:

 CPT® 99243 non-facility = 4.71; facility = 3.96


Consultation - diagnostic service provided by a dentist or physician other than requesting dentist or physician

 Office consultation - 99241, 99242, 99243, 99244, 99245 Inpatient consultation - 99251, 99252, 99253, 99254, 99255

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.




Billing and Coding Guidelines


The Centers for Medicare and Medicaid Services’ (CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an "initial hospital care" code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing f facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.

CPT codes 99241-99245 and CPT 99251-99255 have a status indicator of “I” in the January 2010 National Physician Fee Schedule. The status indicator of “I” is defined as:
“I” = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

For Commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time. Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies.

For example UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-payable service.

For AmeriChoice Medicaid health plans, in state Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS and implement the change, effective January 1, 2010.

For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed by each state to pursue other strategies.

Insurance will consider services when resubmitted with the recommended new or established evaluation and management code (99201-99205; 99281-99285; 99221-99223, 99304-99306) as per CMS guidelines for physicians who see patients in the office or an outpatient/inpatient setting.

This policy shall apply to participating and non-participating professional providers.

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Denial process

CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).In denied instances where the provider is participating, there shall be no member liability.In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

CPT CODE 99243 has to be rebilled as 99203, 99213 or 99283 for Medicre and Medicare HMOs.


BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212
99242 to 99212
99243 to 99213


CPT CODE 99243 - Office visit consultation level 3




CONSULTATIONS

Note: Much of the confusion in reporting consultative services begins with terms used to describe the service requested. The terms “consultation” and “referral” may be mistakenly interchanged. These terms are not synonymous. Careful documentation of the services requested and provided will alleviate much of this confusion.

When a physician refers a patient to another physician it should not automatically be considered a consultation. A consultation would be appropriate if the service provided meets the criteria described below. Services provided that do not meet the criteria below should not be billed using consultation codes.

Louisiana Medicaid reimburses for a consultation, in either a hospital or office setting when:


• The service is performed by a physician other than the attending/primary care physician.

• The consultation is performed at the request of the attending/primary care physician, i.e., the ‘requesting physician’. This physician’s request for the consultation, as well as the need for the consultation, must be documented in the patient’s medical record.

• Consultations should not be requested unless they are medically necessary, unduplicative, reasonable, and needed for adequate diagnosis and/or treatment. The patient’s medical records must be available for review, and the documentation therein must substantiate the need for the consultation. Consultations for patients with simple diagnoses or who require non-complex care are not covered.

• The physician consultant may initiate diagnostic services.

• The consulting physician renders an opinion and/or gives advice to the requesting physician regarding the evaluation and/or management of a patient. The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician.

• Both physicians’ records should be reflective of the request for, and the results of the consultation.

• Confirmatory consultations are not covered.

• All claims are subject to post-payment review.



Billing for Consultations

The following criteria should be used to determine if a consultation code may be billed:

• See “Note” and consultation criteria on the previous page to determine if the service is a “referral” or a “consultation” prior to billing for consultations.

• If the consulting physician is to perform any indicated surgery, a consultation MAY NOT be billed. The appropriate level evaluation and management code may be billed if it does not conflict with global surgery policy. The GSP takes priority over consultation policy for recipients regardless of their age.

• If, by the end of the service, the consulting physician determines and documents in the patient’s record that the patient does not warrant further treatment by the consultant, the consultation code should be billed. If the patient returns at a later date for treatment, subsequent visits should be billed using the appropriate level evaluation and management service codes.

• If, by the end of the consultation, the consulting physician knows or suspects that the patient will have to return for treatment, the appropriate level evaluation and management code should be billed rather than the consultation code. The patient’s record should document the fact that the consulting physician expects to treat the patient again.

Recipients Age 21 or Older

One consultation may be billed in conjunction with diagnostic procedures, if it meets the definition of a consultation as previously described. Follow-up consultations for recipients who are age 21 or older are not covered by Louisiana Medicaid.

Recipients Under Age 21 Outpatient Consultations

• Outpatient consultation policy does not apply to state-funded foster children (aid category 15).

• Three office consultations per recipient per specialty per 180 days are allowed. (The consultant should be a specialist who is asked by the requesting physician to advise him on the management of a particular aspect of the recipient’s care on three different occasions within a six month period.) If a fourth consultation is needed, reimbursement will be made only after the documentation has been reviewed and medical necessity of the additional consultations is approved by Medical Review.



• A consultation by a provider of the same specialty as that of the requesting physician will be allowed when circumstances are of an emergent nature as supported by diagnosis;

and the requesting physician needs immediate consultation regarding the patient’s condition. In this circumstance, no higher consultation code than 99244 should be billed.

These claims will be sent to Medical Review and a review of the documentation will be made before reimbursement is authorized.

• The consulting physician may always bill for the initial consultation, if it meets the definition of a consultation as previously described. However, if the consultant subsequently assumes responsibility for some or all of the patient’s care after the initial consultation, he/she must bill evaluation and management codes for established patients.

If a provider bills an evaluation and management code for the initial visit, the provider cannot then bill a consultation code for subsequent visits.

• Claims for consultations should indicate the name of the requesting provider, which should be different from that of the consulting physician.

• The consulting physician should not have served as the primary care or concurrent care provider within the 180 days prior to performing the consultation.



Inpatient Consultations

• Inpatient consultation policy does not apply to state-funded foster children.

• One initial and two follow-up consultations are allowed per recipient per specialty per 45 days. If a third follow-up consultation is needed, reimbursement will be made only after the documentation has been reviewed and medical necessity of the additional consultation is approved by Medical Review.

• A consultation by a provider of the same specialty as that of the requesting physician will be allowed when circumstances are of an emergent nature as supported by diagnosis; and the requesting physician needs immediate consultation regarding the patient’s condition. In this circumstance, no higher consultation code than 99252 should be billed.

These claims will be sent to Medical Review and a review of the documentation will be made before reimbursement is authorized.


• Only one same-specialty consultation will be allowed every 365 days.

• The consulting physician may always bill for his initial consultation, if it meets the definition of a consultation as previously described. However, if the consultant subsequently assumes responsibility for some or all of the patient’s care after the initial consultation, he/she must bill subsequent hospital care codes for established patients for his daily visit services. If a provider bills a hospital visit code for his initial visit, the provider cannot then bill a consultation code for subsequent visits.

• Claims for consultations should indicate the name of the requesting physician, which should be different from that of the consulting physician. The consulting physician should not have served as the primary care or concurrent care provider within 730 days prior to performing the consultation.


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