| West Virginia Oncology Society |
There has been lots of press around CMS' decision to no longer recognize the consultation codes yet
nothing has changed since the publication of the Medicare Physician Fee Schedule Final Rule. As of
January 1, 2010, CMS no longer recognizes the consultation codes in both the office and hospital
setting. It is important to note that while the codes are no longer recognized by CMS and the Medicare
fee-for-service program, the codes still exist in the AMA CPT manual and are recognized, valid codes
within the manual for other payers.
CMS has released instructions in MM6740 for providers on how these services should be reported after
January 1, 2010. The bullets below provide a brief summary of reporting.
• In the office setting: If a consult is provided in the office setting, then either a new patient visit
code (99201-99205) or an established patient visit code (99211-99215) should be reported.
• The first visit in the hospital setting: If the first visit is in a hospital, then the initial hospital care
codes (99221-99223) should be reported.
• A subsequent visit in a hospital setting: If a subsequent visit is performed in a hospital, then the
subsequent hospital care codes (99231-99233) should be reported.
• The first visit in a nursing facility: If the first visit is in a nursing facility, then the initial nursing
facility care codes (99304-99306) should be reported.
• A subsequent visit in a nursing facility: If a subsequent visit is performed in a nursing facility,
then the subsequent nursing facility care codes (99307-99310) should be reported.
• Use of the -AI modifier: The -AI modifier should be reported by the admitting physician.
MM6740 specifically states that these rules apply to providers participating in the Medicare fee-for-
service program. Providers should contact Medicare Advantage plans and private payers to determine
whether they will continue to recognize the consultation codes or follow the Medicare fee-for-service
coverage rules.
nothing has changed since the publication of the Medicare Physician Fee Schedule Final Rule. As of
January 1, 2010, CMS no longer recognizes the consultation codes in both the office and hospital
setting. It is important to note that while the codes are no longer recognized by CMS and the Medicare
fee-for-service program, the codes still exist in the AMA CPT manual and are recognized, valid codes
within the manual for other payers.
CMS has released instructions in MM6740 for providers on how these services should be reported after
January 1, 2010. The bullets below provide a brief summary of reporting.
• In the office setting: If a consult is provided in the office setting, then either a new patient visit
code (99201-99205) or an established patient visit code (99211-99215) should be reported.
• The first visit in the hospital setting: If the first visit is in a hospital, then the initial hospital care
codes (99221-99223) should be reported.
• A subsequent visit in a hospital setting: If a subsequent visit is performed in a hospital, then the
subsequent hospital care codes (99231-99233) should be reported.
• The first visit in a nursing facility: If the first visit is in a nursing facility, then the initial nursing
facility care codes (99304-99306) should be reported.
• A subsequent visit in a nursing facility: If a subsequent visit is performed in a nursing facility,
then the subsequent nursing facility care codes (99307-99310) should be reported.
• Use of the -AI modifier: The -AI modifier should be reported by the admitting physician.
MM6740 specifically states that these rules apply to providers participating in the Medicare fee-for-
service program. Providers should contact Medicare Advantage plans and private payers to determine
whether they will continue to recognize the consultation codes or follow the Medicare fee-for-service
coverage rules.
| Review of CMS Rules on Consultation Codes |
American Society of Clinical Oncology (ASCO)