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Coding for Medicare consultations

Medicare and some other carriers no longer allow use of the Consult code families. The government made this change to address problems in use of the Consult codes. Other existing codes are to be used in their place. The crosswalk to the other codes is complicated. Prolonged Services codes should be added in some cases. Neurologists need to understand these new rules to be able to code properly for patient care. An overview of rules and a coding crosswalk table are presented here.

Since January 2010, the federal Center for Medicare and Medicaid Services (CMS) has disallowed use of the Consultation evaluation and management (E/M) codes for Medicare patients.1 This has caused great difficulty for US neurologists. It involves both coding and income problems. This article discusses the coding problems and provides examples of how to use the new coding process.

CMS responded to problems using the Consult codes. Too often physicians failed to follow all of CMS's required rules for Consult codes. CMS reasoned that many services coded as Consult should not have been coded as consultations; rather they were new or established patient services. An Office of the Inspector General survey found that 75% of services coded as consults did not meet all of CMS's rules for consultation services.2

This coding rule now has spread beyond Medicare. Many contracts with managed care organizations and health insurance carriers specify the use of Medicare guidelines and payment schedule, usually with a different conversion factor for payment rates. Many of these contracts followed Medicare into disallowing the consultation codes. Medicaid is expected to follow this rule in the near future. The no consult code rule now applies to a sizable fraction of a neurologist's practice case mix.

At the same time, CMS increased payments for the new and established …