Cigna, UnitedHealth to stop paying for consults in October - DoctorsManagement Cigna, UnitedHealth to stop paying for consults in October - DoctorsManagement

Cigna, UnitedHealth to stop paying for consults in October

Grant Huang, CPC, CPMA
Director of Content

Two major commercial payers will stop reimbursing consultation E/M services (CPT codes 99241-99255) in October, finally joining CMS in ditching the high-paying but sometimes confusing code set.

UnitedHealth made its announcement in its March 2019 newsletter, stating that it was aligning its policy to match Medicare’s as part of an effort to shift participating providers to “more current fee schedules.” UnitedHealth will stop recognizing and paying for consults on Oct. 1, 2019.

Cigna’s announcement came more recently in a July bulletin but the company offered no specific explanation. “We will implement a new reimbursement policy, Evaluation and Management (R30), and deny claims billed with CPT consultation codes as not valid,” Cigna writes in the bulletin. “Claims can be resubmitted with the appropriate non-consultative E/M code that describes the service.” Cigna will stop recognizing and paying for consults a little later than UnitedHealth, on Oct. 19, 2019.

 It’s important to note that these changes reflect UnitedHealth and Cigna’s private plans; any of their Medicare Advantage plans were required to comply with Medicare’s elimination of consults back in 2011. That said, for providers and practices who were used to consults for patients with commercial insurance, the change could be a big deal. Let’s revisit the transition from consults and their potential impacts based on the evidence of the last 8 years.

Finally following Medicare

CMS led the charge to abandon the consult codes effective in 2011, creating a “crosswalk” system where providers would bill regular office/outpatient E/M codes 99211-99205 (depending on whether patients were new or established) in place of the outpatient consult codes 99241-99245. Providers seeing inpatients would bill initial hospital care codes 99221-99223 in place of the inpatient consult codes (99251-99255).

The immediate impact was the loss of reimbursement; the work Relative Value Units (wRVUs) for consult codes are anywhere from 5% to 25% higher than their replacement codes, and potentially 50% higher in the case of established patients (the consult codes don’t differentiate between new and established patients while the office/outpatient codes pay significantly less for established patients).

Another change was confusion in the inpatient setting. CMS wanted initial hospital care codes 99221-99223 to replace inpatient consult codes 99251-99255, which required going from five levels of service to three. Training providers on this wasn’t always easy, because providers had to deal with patients from payers who still accepted consults as well as Medicare patients. Even worse was the creation of modifier AI (principal physician of record), which CMS implemented to differentiate inpatient consults from admission services which are billed using 99221-99223.

The admitting physician is supported to append modifier AI so that specialists rendering inpatient consults would be able to report initial hospital care codes on the same day. Very often, the admitting physician failed to do so, and specialists saw their initial hospital care codes denied upfront for being duplicate services.

Fewer requirements, fewer RVUs

Once these difficulties were overcome with provider training and new coding and billing rules, there was the issue of whether or not to stop documenting additional information that was required based on CPT’s description of consult codes.

Consultation codes have additional requirements that other E/M services do not; they require the consulting physician to identify, by name, the provider requesting the consult, along with a reason for the consult, and they are required to send a report with the result of their consultation back to that provider, typically with recommendations for treatment. These unique elements differentiate a consult (which is a request for another provider’s opinion) from a transfer of care, (which is one provider handing the patient off to another provider permanently for treatment of a specific problem or condition).

While some providers found it burdensome to include these elements, others found them helpful for the medical record, and those who choose to keep documenting these elements will continue doing extra work for less reimbursement. Providers who participate with UnitedHealth and Cigna have just a few more weeks to decide whether or not to change their documentation, but they will definitely see a drop in E/M reimbursement.


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