In the beginning of 2010, some dramatic changes in coding and reimbursement for consultation services occurred. Ophthalmologists should understand the associated impact of these changes on their practices, including the financial implications.
Current Procedural Terminology (CPT)—the proprietary coding system of the American Medical Association—adopted new definitions for consultations beginning in 2010. The Centers for Medicare and Medicaid Services, however, is no longer reimbursing physicians that report consultation codes as of Jan. 1. These codes are represented in CPT as 99241 through 99245 (outpatient consultation) and 99251 through 99255 (inpatient consultation). The changes in CPT are found in the introduction section to these codes.
A second definition
The new definition of consultations indicates these codes are relevant when a patient is sent by one physician (or other appropriate source, such as a nurse practitioner) to another physician to render an opinion or advice about a specific condition or problem. This concept should be familiar to physicians that have historically reported consultation services.
However, a second definition now is included. A consultation is deemed to occur when the patient is sent to the receiving physician to "determine whether to accept the ongoing management of the patient's entire care or for the care of a specific condition." Unless it has been predetermined that the receiving physician will be accepting ongoing management, it would seem that this definition would apply to many services rendered by specialists.
Many specialists appreciate the new language in CPT. Based solely on the definitions described, it might be expected that consultation services would be reported frequently.
The new situation with Medicare patients, however, is that physicians must choose different codes to report this type of service. Office consultations are to be reported with the new and established office visit codes CPT 99201 through 99205 and CPT 99211 through 99215, respectively, as applicable.