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UnitedHealthcare delays consultation services payment policy change



October 09, 2017
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement 

UnitedHealthcare (UHC) announced in its October 2017 Network Bulletin that it will indefinitely delay changes to its consultation services payment policy, which would have discontinued reimbursement for CPT codes 99241-99245 and 99251-99255. 


Citing alignment with a policy implemented by the Centers for Medicare and Medicaid Services, and in response to misuse of consultation service codes, UHC had previously announced that it would no longer reimburse consultation services for commercial product lines effective October 1, 2017. In lieu of a consultation service code, physicians would have been required to bill utilizing the appropriate evaluation and management (E/M) procedure code that describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care.


The California Medical Association (CMA), in conjunction with a number of other state medical societies, to UnitedHealthcare expressing serious concerns regarding its decision to no longer pay for consultation codes. In the letter, the organizations questioned UHC’s claim that this change will be a “budget neutral experience” due to Relative Value Unit changes made in recent years to E/M codes. The joint letter also questioned UHC’s statement that it found a misuse of consultation codes for commercial patients after an extensive data survey. Instead, CMA and others recommended that UHC address concerns with physicians directly rather than implement a broad policy penalizing physicians who bill these codes correctly.


Practices that have additional questions can contact UnitedHealthcare Network Management or their assigned UHC Physician Advocate.

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