Medicare consultation code policy guidance

11 January 2010

Effective January 1, 2010, Medicare no longer recognizes CPT consultation codes (CPT code 99241 to 99245; and 99251 to 99255) for inpatient facility and office/outpatient settings.  Instead, initial evaluations conducted in the inpatient hospital setting and nursing facility setting should be billed as an initial hospital care visit (CPT code 99221 to 99223) or nursing facility care visit code (CPT code 99304 to 99306), when appropriate.  The “AI” Principal Physician of Record modifier should be appended to the E/M code when Medicare is billed by the admitting physician; the modifier should not be used by the consulting physician.

The new CMS policy does not apply to Medicare Advantage plans; however, plans may individually elect to apply the new policy.

The Centers for Medicare and Medicaid Services (CMS) has issued guidance on these recent revisions including appropriate coding for several outpatient, observation, and emergency department scenarios.  Additional information is available in CMS Transmittal #1875.