Recently, healthcare practices have been experiencing a high number of claim denials when billing and reporting consultation codes (99241-99245, 99251-99255) to private insurance companies. This problem started after CMS chose to remove these consultation codes starting in January 2010.

Some insurance companies have decided to keep paying for these consultation codes, while others are following the new CMS policy. Starting out, many insurance companies chose to keep accepting consultation codes to maintain the flow and consistency for healthcare practices.

For healthcare practice consultants, it is important to know the latest policies of the insurance providers they work with. This is because recently, many big insurance companies like United Healthcare, Cigna, and Anthem said they will stop accepting consultation codes.

Did you see that your insurance payer has stopped paying for the consultation codes? If your patient’s consultation code keeps getting denied, it may mean that your insurance provider is not interested in accepting these codes anymore.

This blog will tell you about the insurance payers that do not accept consult codes.

Why Consult Codes Are Used?

Consultation codes are used to charge for consultation services given by healthcare providers. This code connects insurance companies and healthcare providers to pay for services given. Consultation codes that are part of the CPT code range are grouped based on their complexity and the type of setting for the consultation. These include:

• Codes for outpatient consultations: (99242-99245)
• Codes for inpatient consultation: (99252-99255)

Always remember the three important “R’s” of consultation codes. They are key parts of the medical billing process for consultation services.

1). Request

The first consultation request from one doctor to another: the request’s documentation needs to include the grounds for the consultation as well as the particular issues that need to be resolved.

2). Render

The second “R” for consultation services represents the process by which healthcare providers assess patients and order any required tests by looking through their medical records.

3). Reply

Following a consultation with healthcare providers, it’s time to offer written reports to the consulting providers as feedback. This report includes all findings, recommendations, and a treatment plan for managing the patient’s condition.

These three “R’s” help make communication clear and ensure proper documentation of patients, which is important for accurate coding and billing.

Insurance Payer Interpretations of 2010 CMS Consultation Code Guidelines

After the CMS policy update on January 1, 2010, different payers decided if they would follow CMS’s decision or keep accepting these codes. We have included a full table from the American Academy of Professional Coders (AAPC) showing which payers decided not to accept the consultation code and which payers still accept it after the CMS decision in 2010.

Since 2010, the number of insurance payers that do not accept consultation codes has grown a lot. At first, CMS worked to eliminate consultation codes. Over time, many private insurers did the same. UnitedHealthcare said in 2019 that it would stop accepting consultation codes. Aetna, Cigna, and many other insurance companies have made similar rules like CMS.

As a result of this, healthcare providers needed to change by using different Evaluation and Management (E/M) codes to explain their services. E/M codes help to record and charge for patient visits, depending on how complicated and what type of the visit is. The codes are from 99201 to 99215 for office or outpatient services, and from 99221 to 99223 for initial hospital care. The change to E/M codes makes sure that the services given are recorded correctly and paid for, even if consultation codes are not used.

This change needed healthcare workers to be careful in their documentation to make sure they follow the rules for the right E/M code. This includes things like the patient’s history, examination, and how complex the medical decisions are.

Aetna’s Policy Updates for Consultation Code

Aetna used to pay for consultation codes, even after CMS said they would stop accepting them in 2010. However, Aetna stopped paying for these consultation codes from November 1, 2022. Aetna made this choice to follow healthcare industry rules and ensure appropriate billing procedures.

CIGNA’s Policy Updates for Consultation Code

Starting in October 2019, Cigna stopped accepting the consultation codes for inpatient consultations (99251-99255) and for office consultations (99241-99245). This change means that claims sent to Cigna with these codes can be rejected and not accepted at all. Healthcare providers must use the non-consultative E/M codes.

This is a comparison of the Cigna policy and the CMS policy.

Key Aspects	CMS	Cigna
Consultation Codes	99241-99245(office), 99251-99255(Inpatient)	99241-99245(office), 99251-99255(Inpatient)
Policy Effective Date	January 1, 2010	October 19, 2019
Reimbursement Status	No longer reimbursement for consultation codes	No longer reimbursement for consultation codes
Alternative Codes	Other E/M codes (99201-99215)	Other E/M codes (99201-99215)
Relative Value Unit (RVUs) Adjustment	Increase relative value for E/M  codes	No specified yet

UnitedHealthcare’s Policy Updates for Consultation Code

UnitedHealthcare’s new policy explains what is needed to submit claims for consultation codes. Starting June 1, 2019, UnitedHealthcare does not cover consultation code reimbursement anymore. These modifications to the reimbursement policy comply with CMS criteria and are applicable to healthcare providers whose payment schedule is now based on metrics like CMS Relative Value Units (RVUs) and the Percentage of Charge Rate.

Anthem’s (Blue Cross Blue Shield) Policy Updates for Consultation Code

On July 1, 2021, Anthem (Blue Cross Blue Shield) shared an important update about their payment policy for consultation codes. This update is called a “Notice of Material Amendment/Change to Contract (MAC).” This policy change started on October 1, 2021. It means that Anthem will not pay healthcare providers for using inpatient and outpatient consultation codes anymore.

Providers must begin using the right E/M visit codes to report these services so they can get paid correctly. This change followed CMS rules about consultation codes. It aimed to help providers report more consistently and make sure they get the right payment for the services they provide.

Why Did CMS Stop Paying for Consultation Codes?

The Centers for Medicare & Medicaid Services (CMS) has decided to stop paying for consultation codes. This is to fix problems with verifying if doctor consultations are acceptable. This change is to make the billing process easier and to have better and more consistent records.

1). Cost-Savings Policy

The Centers for Medicare & Medicaid Services (CMS) stopped reimbursing for consultation codes in 2010 as a cost-saving measure. This policy change happened because there is a big difference between consultation codes and evaluation and management (E/M) codes for similar services.

Consultation codes were paid at a much higher rate, costing the Medicare program about $500 million more each year than if the same services were billed with E/M codes. The higher payment rates encouraged doctors to use consultation codes, even if an E/M code might have been a better choice.

CMS wanted to cut down on extra spending by removing consultation codes. They plan to use the saved money for other important healthcare services. The policy change required the use of E/M codes. These codes are paid at a lower, more suitable rate for regular patient check-ups and care coordination. This saving helps keep the Medicare program’s finances strong and makes sure there is money to pay for medically necessary services.

So the main reason CMS decided to stop paying for consultation codes was to save money for the Medicare program. Stopping the use of expensive consultation codes helped CMS save money and use those funds for important medical care for patients.

2). High Error Rate

CM stopped paying for consultation codes mainly because there were many mistakes in how these codes were billed.

Consultation codes were often billed wrong, leading to many denials that caused problems for both healthcare providers and insurance companies. Inaccurate billing caused many claims to be denied. This meant providers had to send claims again, which delayed payments. It also made it hard for CMS to track and manage healthcare costs when the consultation codes were used in different ways.

CMS wanted to cut down on claim mistakes and denials by removing payment for consultation codes. They introduced evaluation and management (E/M) service codes as a replacement option with more clear billing guidelines. The aim was to make the new E/M codes simpler for providers to use correctly, making the claims process smoother. Changing coding can cause some problems at first, but CMS believed that using E/M codes for a long time would make billing more consistent and reduce the mistakes in claims that had been a problem with consultation code billing.

Therefore, the high number of wrong consultation code bills was also one of the main reasons why CMS decided to stop reimburse consultation codes. CMS changed to E/M codes with simpler rules to help reduce mistakes in claims and make billing more accurate for both providers and payers.

3). Inconsistency in Code Handling by Payers

Among the reasons CMS decided to stop covering consultation codes was to promote uniformity among different payers. Before this policy change, different payers treated consultation codes in different ways. Some payers accepted them, but others did not. This caused confusion and differences in billing practices among healthcare providers.

CMS stopped using consultation codes to make coding and billing more uniform for all payers. This consistency makes the claims process easier and ensures that providers use the same codes for similar services, no matter which payer they are billing.

Now, instead of consultation codes, providers use Evaluation and Management (E/M) service codes to charge for consult services. E/M codes are a coding system that everyone understands and accepts. This keeps billing and payments the same, no matter who is paying.

For example, a family doctor sends a patient to a heart doctor for advice. Before the policy change, the heart doctor might have used a consultation code for billing if the patient’s insurance allowed it. If the insurance did not accept consultation codes, the cardiologist would need to use a different code. This could cause confusion and problems with billing.

Now, with E/M codes, the cardiologist can always bill using the right E/M code for the service given, no matter the patient’s insurance company. This makes sure that coding and billing are the same for all payers, which helps to reduce confusion and possible billing mistakes.

4). Lack of Value-based Care

CMS has stopped paying for consultation codes as part of its broader shift towards value-based care. The main reason for this change is to make sure that healthcare providers concentrate on giving good care to patients instead of just doing certain tasks.

In the old fee-for-service system, healthcare providers were encouraged to do more services because they got paid for each service they provided. This method often resulted in extra or repeated services, increasing healthcare costs without really helping patients more.

Now, CMS is using Evaluation and Management (E/M) codes to pay healthcare providers because of the move to value-based care. These codes show how complex and valuable the services are. They consider things like the patient’s health, how much decision-making is needed, and the time spent with the patient.

CMS promotes a patient-centered approach to healthcare by encouraging providers to use E/M codes. This helps them prioritize comprehensive, coordinated care that addresses all of the patient’s health needs, rather than just focusing on specific services. This method supports the aim of value-based care, which wants to make patient health better and lower healthcare costs.

For example, before the change to value-based care, a healthcare provider might have been encouraged to do many consultations for a patient, because each consultation would earn a separate payment. Under the new model, the provider will get paid based on how complicated the patient’s condition is and how much care is needed, no matter how many consultations are done.

This change helps to reduce unnecessary services and encourages healthcare providers to look at the whole patient. It focuses on the patient’s overall health needs and makes sure care is coordinated among different healthcare settings and providers.

5). Absence of Proper Documentation

Previously, doctors could use consultation codes to charge for giving their opinion or advice about a patient’s health. But, these codes did not always need a lot of details about the patient’s history, exam results, and the choices made by the doctor. Not having enough complete documents can cause patient records to be missing important information and may create problems during audits or reviews.

To solve this issue, CMS now asks providers to use Evaluation and Management (E/M) codes. These codes require them to write down important details about the patient’s history, physical exam, and the complexity of the medical decisions made. Providers must carefully write down the patient’s condition, the services given, and the reasons for their clinical choices by following these documentation rules.

Using E/M codes helps to create clear and complete documentation for several important reasons:

1. Better patient records: Clear documentation makes sure that patient records show the care given. This helps in keeping care consistent and allows other healthcare workers to understand the patient’s condition and treatment plan.
2. Better choices in healthcare: Clear records of the patient’s history, examination results, and medical choices help doctors make informed decisions and ensure the right treatment is given.
3. Correct billing and payment: Good documentation helps during audits and reviews. It makes sure that the services charged are needed for the patient’s health, suitable for their condition, and truly show the care given.

CMS wants to make patient records better by removing consultation codes. This will help improve the quality of records, support better decisions in healthcare, and make sure billing and payments for services are correct. This change highlights how important it is to have clear and correct documents for providing good patient care.

Impact of the 2010 CMS Decision on Healthcare Billing and Fraud Prevention

In 2010, the Centers for Medicare & Medicaid Services (CMS) made a major decision to make billing easier and to lower fraud. This rule required healthcare providers to use Evaluation and Management (E/M) codes for visits that happen in and out of the hospital. This important change in policy required updates to the Relative Value Unit (RVU) for E/M medical codes to make sure healthcare services are paid fairly.

Impact on Global Surgery Allowance

To account for the elimination of consultation code reimbursements, CMS has increased the work Relative Value Units (RVUs) assigned to Evaluation and Management (E/M) codes. These E/M codes are bundled into global surgery packages, which cover the procedure itself and follow-up care for a specified period, typically ranging from 10 to 90 days after the surgery.

The increase in work RVUs for E/M services means that physicians will receive slightly higher reimbursements for the post-operative care included in global surgery packages. However, it’s important to note that this impact on overall payments is expected to be minimal because the E/M visits represent only a small portion of the total reimbursement for global surgery packages, which are primarily driven by the procedure itself.

To validate this point, we can look at the Medicare Physician Fee Schedule, which outlines the RVUs and corresponding reimbursement rates for various medical services. Historically, the work RVUs assigned to E/M codes have been relatively low compared to the work RVUs for surgical procedures. As a result, even with the slight increase in E/M work RVUs, the overall impact on global surgery payments is likely to be nominal.

Additionally, it’s worth considering that the elimination of consultation codes may lead to more efficient billing practices and reduce administrative burdens for healthcare providers, as they no longer need to differentiate between consultations and other types of visits.

Impact on Providers: Fee Adjustments and Budget Neutrality

To maintain budget neutrality, CMS will increase work RVUs for certain services. Specifically, there will be approximately a 6% increase to RVUs for new and established office visits and a 2% increase for nursing facility and initial hospital visits. CMS has implemented a crosswalk to transition the values for consultation codes to new codes while preserving budget neutrality.

The crosswalk maps consultation codes to new patient office/outpatient codes. This increases RVUs for office visits to account for the additional work required for an initial patient encounter. The crosswalk also maps consultation codes to established patient office/outpatient codes. This smooths the transition for consultations converted to established visits. By deliberately adjusting work RVUs in this manner, CMS aims to keep overall payments budget neutral while eliminating consultation codes.

Final Thoughts

Insurance Providers	Reimbursement Status	Policy Change Effective Date (Day-Month-Year)
Aetna	❌ Doesn’t Accept Consultation Codes	1-11-2022
Anthem – Commercial	❌ Doesn’t Accept Consultation Codes	1-1-10
Anthem – Medicare	❌ Doesn’t Accept Consultation Codes	1-10-21
CIGNA	❌ Doesn’t Accept Consultation Codes	1-10-19
Humana Medicare – MCHMO & MCPPO	❌ Doesn’t Accept Consultation Codes	1-1-10
Rocky Mountain Health Plans	❌ Doesn’t Accept Consultation Codes	1-4-10
UnitedHealthcare – Medicare Solutions	❌ Doesn’t Accept Consultation Codes	1-1-10
UnitedHealthcare – Commercial	❌ Doesn’t Accept Consultation Codes	1-6-19

Many insurance companies, like Cigna and Aetna, have stopped accepting consult codes due to billing accuracy and cost concerns. This critical change shows that healthcare providers need to switch to E/M codes for consultation services. Remember, healthcare providers, you need to stay updated on the latest payer policies for your contracts. This can help you avoid claim denials and significant revenue loss.

How do you stay updated with the latest policies?

You should remain in touch and talk regularly with your payers. Plus, you can visit their website regularly to see any changes in policies.