Consultations in 2023

Question:

I am putting together E&M Guideline educational information for my providers based on the 2023 changes for reference throughout the year. I did some education in 2022 and now working on the tools. In 2022, I kept hearing that inpatient and outpatient consultation codes were being deleted. However, they are still listed in the 2023 CPT Manual. Are you able to help me?

Answer:

You are correct; the inpatient and outpatient consultation services (i.e. 99242-99245 and 99252-99255) remain valid CPT codes in 2023. Perhaps the point of confusion is that CPT codes 99241 and 99251 were deleted to align the Medical Decision Making (MDM) levels with the levels that were defined in 2021 for the office outpatient codes and the 2023 hospital changes.

Remember, Medicare does not accept consultation codes and nothing changes for Medicare in 2023; the consultation codes in the Medicare fee schedule continue to have an Invalid code status. Some private payors have published guidelines stating they do not allow payment for consultations, but the codes remain current; there are payors who still recognize consultation codes.

Retinacular Repairs

Question:

Our surgeon documented a repair of the patella tendon with repair of the medial retinaculum repair. The surgeon wants to code for the retinacular repairs and I can’t find a CPT code. Are you able to assist?

Answer:

Thanks for your inquiry. A retinacular repair is inclusive to other surgical repairs (e.g. tendon or ligament) thus there is no additional code to report.

Secondary Payor Doesn’t Recognize Consultations

Question:

We have a patient with 2 commercial payers (BCBS and Cigna). A consultation code was submitted to BCBS, and they paid according to our contract. However, Cigna is refusing to process the claim since they no longer pay for consult codes. Am I allowed to change the CPT code and rebill Cigna? Or would I need to change the CPT, refile to the primary as a corrected claim, then send the balance on to Cigna?

Answer:

We suggest calling CIGNA and ask how they want this handled according to their policies. WithMedicareyou have two options: (1) bill the appropriate category and level of service documented (e.g., for outpatient consults [99202-99215] or inpatient consults [99221-99223]) or (2) bill the consultation code, which will result in a denial of payment from Medicare and appeal on paper explaining the situation.

E&M Coding Based on Time

Question:

Our physicians default to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own independent interpretation of X-Rays (we bill globally), perform injections, and reduce fractures in the office. They are counting the total time spent with the patient, including these activities and we do not believe that is correct. Can you help?

Answer:

Thank you for your inquiry. We will not address the default to time for almost every encounter other than to say medical necessity must be present for time spent.

With that said, the activities you identify, because they are billable services represented by other CPT codes (aka are separately reported), do not contribute to the total time spent; this time must be deducted from the total time, assuming the E&M service is reportable.

SI Joint Injection

Question:

What CPT code do we use when our physician performs an SI joint injection using ultrasound guidance? CPT code 27096 states with fluoroscopy or CT guidance.

Answer:

CPT instructs to report CPT code 20552 for unilateral or bilateral SI joint injections if CT or Fluoroscopic imaging is not used. CPT code 76942, for the ultrasound guidance, may be reported if the documentation requirements are met.

source: CPT Assistant April 2022

E&M Coding Based on Time

Question:

When choosing the level of E&M we are confused about the History and Exam. If we choose a level of E&M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E&M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. As displayed below in bold font, obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (eg, review of tests);
• obtaining and/or reviewing separately obtained history;
• performing a medically appropriate examination and/or evaluation;
• counseling and educating the patient/family/ caregiver;
• ordering medications, tests, or procedures;
• referring and communicating with other health care professionals (when not separately reported);
• documenting clinical information in the electronic or other health record;
• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and
• care coordination (when not separately reported).

These guidelines currently apply only to E/M codes 99202-99215 that are used in the office/outpatient setting.
source: CPT Assistant April 2022