CPT® Consult Rule Changes for 2010

November 2nd, 2009 - Codapedia Editor

Categories: Coding CPT^® Coding Evaluation & Management (E/M)

By now you've heard the news that starting January 1, 2010, Medicare will no longer reimburse consultation services billed with codes 99241--99245, 99251--99255. But, the consult codes remain in the CPT® book for 2010. However, there is quite a bit of new editorial material related to consults. When you receive your CPT® book for 2010 (if you haven't already), compare what it says to the editorial descriptions for 2009. If you have bought the Professional Editioni of the book, which I recommend, the changed test is in green.

CPT® added this to its definition of outpatient consults, "...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." Later in the section, the AMA adds, "Services that constitute a transfer of care (ie, are provided for the management of the patient's entire care or for the care of a specific condition or problem) are reported with the appropriate new or established...."

Where have we read something like this before? In the Medicare Claims Processing Manual, in CMS's explanations of what constitutes a transfer of care, and is thus not a consult and in detail in the 2009 Proposed Physician Fee Rule. In that rule, CMS commented that they perceived that the AMA did not help the physician community to understand the concept of transfer of care, as CMS pointed out in its proposed and final rules this year. As coders, consultants and managers, we tried to clarify the intent of the requesting clinician by asking the requesting clinician if they wanted "evaluation only" or "evaluation and management" or "consult and treatment" but none of those helped much.

The CMS, and now CPT®, description of transfer of care included transfer for the patient's entire care or for the care of a specific condition or problem. As Medicare said, using that definition of transfer of care would decrease the frequency of consults. The new CPT® definition would allow more consults because it still allows a consult in the case where the consultant must "determine whether to accept responsibility for..."

For 2010, it remains to be seen how commercial payers whether payers will follow CMS policy and stop paying for consults, and how they will interpret this new guidance from CPT®.

The other significant change in the AMA's editorial information about consults is that they say that the request for consult should be documented in the patient's medical record by "either the consulting or requesting physician or appropriate source." That is a more liberal allowance for consults than we had from Medicare. The CPT® editorial description does not say the request should be documented by both the requesting and consulting clinicians. CPT® keeps its "or other appropriate source" allowance, however, in practice, for all payers, a requesting clinician must have an NPI number in order to bill a consult.

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