Starting October 1st, 2017, UnitedHealthcare will join the ever-growing list of insurance providers that do not offer reimbursement for consultation codes. Citing the rationale of “commitment to…improving healthcare services,” UHC will no longer offer reimbursement for CPT codes 99241-99245 and 99251-99255. This change comes seven years after Medicare made the switch, so while many medical professionals are understandably upset, the change is hardly unprecedented.
But with such a drastic shift coming, what can providers do to receive the reimbursement they deserve? To start, try to find an evaluation and management (E&M) code that covers the same service. For example, it may be possible to cover inpatient consultation codes with initial hospital care service codes 99221-99223.
Of course, these codes may not always meet the same minimum key components as the consultation codes. In that case, the search can get a bit trickier. For example, sometimes subsequent hospital care codes offer the necessary level of problem-focused history. Do not worry if this substitution comes across as unnatural in the documentation; the Centers for Medicare and Medicaid Services (CMS) revised their policies to account for the influx of E&M codes when they eliminated consultation reimbursement, and UHC will likely do the same.
If all of these options still do not yield a code that properly covers all the necessary elements, consider defaulting to 99499, unlisted evaluation and management service. Though this code should never be an initial pick, it serves as a good last line of defense for these exact situations. Keep in mind, however, that because of its inherently vague nature, reporting this code requires the submission of medical records to prove its necessity. This same code is also a frequent target for audits, so if you find yourself with no choice but to use it, be sure to document the medical necessity as extensively as possible.