If a patient that has Traditional Medicare and a secondary coinsurance, when, if ever, is it appropriate or is it payable to bill for a consultation code such as CPT 99243 or CPT 99244?
As of January 1, 2010 the Centers for Medicare and Medicaid Services stopped paying for consultation E/M codes. While it continued to recognize the concept of consults, it reimburses them using new and established patient visit codes (CPT 99202 – CPT 99215). Therefore, if a patient has traditional Medicare and a secondary insurance to cover the 20% that Medicare does not reimburse, depending upon the place of service (POS) where the consultation was performed, the appropriate E/M service codes for that specific Place of Service are used for the consultations that were performed.
Most commercial health insurance carriers have followed CMS/Medicare’s lead and no longer reimburse for the consultation E/M codes. However, it is possible that some private health insurance carriers still require the consultation E/M codes to be used. Therefore, it is important to confirm with the health insurance carrier in advance to determine whether the consultation E/M codes or the E/M codes for the Place of Service where the consultation was performed are appropriate to use.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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