Medicare’s transformation of consultation coding has taken a new twist in the arena of lower-level hospital consults.

Without national guidance from CMS, different Medicare contractors are giving conflicting instructions to providers on billing for consultations that don’t qualify for any of the three evaluation and management (E/M) codes now used for inpatient consults. None of the instructions suit compliance officials, who cite the financial and compliance drawbacks.

A CMS spokeswoman tells RMC that the agency “will be providing additional guidance soon.” Until then, Medicare contractors have been told to do as they see fit.

The challenge with billing lower-level consultations emerged as CMS eliminated consultation codes, including inpatient consult codes (CPT 99251 to 99255). Effective Jan. 1, 2010, physician consults are billed to Medicare under regular E/M codes. For example, consulting physicians will use 99221 to 99223 for initial inpatient evaluations and 99231 to 99233 for subsequent hospital visits. That means five levels of consultation services must now fit into three levels of services.

As it turns out, some physician consults wind up in a black hole. They don’t rise to the level of a 99221 initial inpatient visit because the patient exam, history and/or medical decision making is not complex or comprehensive enough (according to Medicare E/M documentation guidelines). But with CMS apparently planning to keep writing checks for low-level consults, Medicare contractors had to devise ways to process these claims.

Some Medicare administrative contractors are telling hospitals and physicians to bill lower-level consultations under unlisted CPT code 99499. For example, Wisconsin Physicians Service (WPS) Medicare recommends the use of 99499 “in the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description…” (see Internet Only Manual Pub. 100-04, Chapter 12, Section 30.6.1.B, “Selection of Level Of Evaluation and Management Service”). Florida-based First Coast Services Options and South Carolina-based Palmetto GBA are two additional contractors that are requiring providers to use unlisted code 99499 to report low-level hospital consultations.

Other contractors want these consultations reported as subsequent hospital visits because they believe the use of the unlisted code is inappropriate. “Unlisted code 99499 should not be used to code consultation services,” National Government Services, the MAC for 10 states, said in a recent slide presentation. Similarly, Highmark Medicare Services, the MAC for Pennsylvania and four other states, noted in a letter to a medical center that “CMS’s guidelines do not recommend or advise the use of CPT code 99499.”

TrailBlazer: Better to ‘Miscode’ in this Context

But WPS asserts on its Web site that “we follow AMA CPT coding logic and it is not permissible to bill a subsequent prior to an initial. Bottom line, always bill an initial service prior to a subsequent hospital visit.”

Then there’s the logic of TrailBlazer Health Enterprises, the MAC for four states (e.g. Texas, Colorado). It acknowledges that billing a subsequent hospital visit before an initial visit is counterintuitive, but explains why providers should choose subsequent care hospital codes over unlisted code 99499. “Reporting 99499 requires submission of medical records and contractor manual medical review of the services prior to payment,” the contractor says on its Web site.

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