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These frequently asked questions (FAQ) were developed to answer questions about AmeriHealth New Jersey?s new position regarding reimbursement for consultation codes as outlined in Claim Payment Policy #00.01.64: Consultation Codes.
Note: This document will be updated as additional information becomes available.
1. Why has AmeriHealth New Jersey updated its reimbursement position for consultation codes?
At AmeriHealth New Jersey our mission is to enhance the health and well-being of the people and the communities we serve. That means that every day we face an important challenge: balancing our commitment to fairly and competitively compensate physicians and hospitals with our responsibility to keep health care affordable for our members ? all while conducting business in a region where utilization and cost of care are amongst the highest five metropolitan statistical areas consistently with only average outcomes for leading health indicators and lower than average consumer satisfaction rates.
Based on a review of the Centers for Medicare & Medicaid Services (CMS) standards, AmeriHealth New Jersey is adjusting its position regarding provider payments for consultation codes. Our decision was based on the following:
- Consultation codes 99241 through 99245 and 99251 through 99255 have not been recognized for Medicare Part B payment by CMS since January 1, 2010.1
- Key aspects of CMS?s rationale for the change include:2
- – The associated physician work between inpatient and office/outpatient consultation services and initial hospital care and new patient office/outpatient visits is clinically similar.
- – The rationale for a differential payment for a consultation service is no longer supported because documentation requirements are now similar across all evaluation and management (E&M) services.
- The change will help reduce out-of-pocket costs for members with high-deductible and coinsurance plans, based on reduced allowed amounts for appropriate E&M services billed in lieu of consultation codes.
2. What is the update to our reimbursement position for consultation codes?
Effective January 1, 2018, when rendering services to AmeriHealth New Jersey members, we will no longer recognize the Current Procedural Terminology (CPT®) consultation codes 99241 through 99245 and 99251 through 99255 as eligible for reimbursement. Instead, providers need to code patient E&M visits with E&M codes that represent where the visit occurred and identify the complexity of the visit performed.
3. What is the effective date of this change?
Claim Payment Policy #00.01.64: Consultation Codes is effective for AmeriHealth New Jersey claims submitted with a date of service on or after January 1, 2018.
4. Which providers will be impacted by this update?
This update will apply to all professional providers who render services to AmeriHealth New Jersey members.
5. How have or will providers be notified of the update to the policy?
On October 3, 2017, this policy change was announced to providers via:
6. Will this policy affect telehealth consultation codes G0425 through G0427?
No. The policy will only apply to consultation codes 99241 through 99245 and 99251 through 99255. AmeriHealth New Jersey will continue to reimburse for CPT codes G0425 through G0427 as per its current contracted fee schedule.
7. Is there a direct crosswalk from consults to office/outpatient visits or consults to hospital or facility visits?
No. Keeping in line with CMS, AmeriHealth New Jersey did not design a direct crosswalk. In the 2010 Medicare Physician Fee Schedule, CMS states, ?It is not necessary to develop any complicated coding crosswalk or guidelines for translating the consultation code requirements for purposes of applying the visit codes. The major effects of the provision may actually simplify coding because physicians will use the office and hospital visit codes in place of consultations and will not have to determine whether the requirements to bill a consultation are met.?
Providers should code patient E&M visits with E&M codes that represent where the visit occurred and identify the complexity of the visit performed.
8. What codes should physicians use for the first visit to the office?
For dates of service on or after January 1, 2018, if no other provider in the same specialty in your practice has provided any face-to-face service to the patient in the last three years, you should bill the New Patient Visit codes 99201 through 99205. If the patient has been seen within the last three years, you should bill the Established Patient Visit codes 99211 through 99215.
9. What codes should be used when seeing a patient for the first time in the hospital?
Providers should use the Initial Hospital Visit codes 99221 through 99223. If you are the admitting physician, add the AI modifier to the code.
10. What codes should be used when seeing a patient in the emergency room?
Providers should use the Emergency Department Visit codes 99281 through 99285.
11. What will happen if I continue to bill a consultation code on or after January 1, 2018?
Providers who bill an E&M service on or after January 1, 2018, using consultation codes 99241 through 99245 or 99251 through 99255 will have the claim denied. Their Provider Explanation of Benefits will contain a message indicating that the service is not eligible for reimbursement. To receive payment for the E&M service, the claim should be resubmitted using the appropriate E&M code as described in the claim payment policy.
For more information
Please refer to the Medical Policy Portalto view the most recent version of the policy, as they will supersede the information in this FAQ.
If you cannot find the information you are looking for here and have further questions, please email us at
consultcodes@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email.
You can download a PDF of this FAQ here.
1 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6740.pdf
2 https://www.gpo.gov/fdsys/pkg/FR-2009-11-25/pdf/E9-26502.pdf
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