August 01, 2017
Area(s) of Interest: Commercial Payors Public Payors
Citing alignment with a policy implemented by the Centers for Medicare and Medicaid Services (CMS), and in response to misuse of consultation service codes, UnitedHealthcare (UHC) has announced that it will no longer reimburse consultation services for commercial product lines effective October 1, 2017. Consultation services previously represented by CPT codes 99241-99245 and 99251-99255 will now need to be billed 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,issued a letter to UnitedHealthcare expressing serious concerns regarding its decision to no longer pay for consultation codes. In the letter, CMA and others questioned UHC’s claim that this change will be a “budget neutral experience” due to Relative Value Unit changes made to E/M codes in recent years. The joint letter also questions 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.
If you have any additional questions or wish to voice concerns about the UHC policy change, please contact UnitedHealthcare Network Management or your assigned UHC Physician Advocate.