Is Professional Consultation Billable to Medicare?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

As you know, managing patients with chronic ulcers requires physicians and other qualified healthcare professionals (QHPs) with specialized knowledge and expertise. Unfortunately, this country has a shortage of chronic ulcer management professionals. Therefore, many physicians/QHPs who do not have the required knowledge do their best to manage chronic ulcers by trial and error. Many of these physicians/QHPs wish they could consult with physicians/QHPs who have chronic ulcer management expertise. In addition, even the physicians/QHPs who have such expertise are often stumped on difficult cases and wish they could consult with other colleagues who may have experienced similar cases.

If you have ever been in any of these situations, the consultation below should be helpful to you.

Scenario

Several well-known chronic ulcer management physicians contacted me. They have been receiving an increasing number of calls from 1) physicians in areas of the country that do not have access to wound/ulcer management specialists, and 2) from their colleagues across the country who seek their advice about difficult patients. All of these specialists expressed that they did not mind sharing their expertise, but that the volume of calls was cutting into their office hours.

All of the physicians, except for one, thought they should and could charge for these consultations. The physician, who did not think they could charge for their services, based that on the fact that the consultation codes were not payable by Medicare. Therefore, they engaged me to provide teleconsultation education for the entire group. They wanted to know the correct answer.

Facts to Consider

•      Medicare does not pay for the codes 99241–99245 Office consultation for a new or established patient.
•      Medicare does pay for interprofessional telephone/internet/electronic health record (EHR) consultations, commonly called “eConsults.”

Consultation

First, I complimented the physician who was certain that Medicare did not pay for office consultations. When I asked this physician to list the consultation codes that are not paid by Medicare, she correctly listed the evaluation and management CPT^®1 codes 99241–99245.

Second, I complimented all the other physicians who were certain that Medicare does pay for some consultations. However, when I asked these physicians to list the consultation codes that are paid by Medicare, they listed the same CPT codes: 99241–99245. Their coding misperception began the consultation and education session, during which we discussed the following topics:

•      Medicare ceased paying for office consultations (99241–99245) many years ago.

•      In 2014, the American Medical Association (AMA) created codes for non–face-to-face interprofessional telephone/Internet consultations (99446–99449), which could be reported by the consulting physician, who had specific specialty expertise, to assist the treating physician. However, the AMA did not create codes for the treating physician who requested the consultation.

•      In 2019, the AMA revised the description of the consultant codes (99446–99449) to include the electronic health record as one of the non–face-to-face modalities. The AMA also added two new codes: 99451 for a consultation that concludes with only a written report, and 99452 for the treating physician who requested the consultation. All of these codes are still active and payable by Medicare.

•      In 2022, a treating physician may request an eConsult from a physician who specializes in chronic ulcer management as long as the interprofessional consultation is conducted via the telephone, Internet, or the electronic health record. I encouraged the physicians to read that section of CPT 2022 and discussed some of the instructions that pertain to each of the codes.
    o   99452 include 30 minutes in the code description. Therefore, the physician or QHP who requests the eConsult should report 99452 if she/he spent 16–30 minutes preparing for the referral and/or communicating with the consultant. If more than 30 minutes were spent, the requesting physician/QHP may report the prolonged services codes.
    o   99446–99449 should be reported by a consulting physician who provides a verbal and written report. These codes are time-based and greater than 50% of the time should be devoted to medical consultative verbal or Internet discussion.
       §  99446 for 5–10 minutes of medical consultative discussion and review
       §  99447 for 11–20 minutes of medical consultative discussion and review
       §  99448 for 21–30 minutes of medical consultative discussion and review
       §  99449 for 31 minutes or more of medical consultative discussion and review
    o   As stated above, 99451 should be reported by a consulting physician who only provides a written report. This is a time-based code and should be reported for 5 minutes or more of medical consultative time.
    o   These interprofessional consultations can be performed for either new or established patients.
    o   The consultant should not have seen the patient in a face-to-face encounter within the last 14 days.
    o   These codes should not be reported if the consultation leads to a transfer of care or some other face-to-face service within the next 14 days or the next available appointment date of the consultant.
    o   Consultative time spent is cumulative over 7 days. Do not report 99446, 99447, 99448, 99449, or 99451 more than once within a 7-day time period.
    o   The treating/requesting physician’s/QHP’s written or verbal request for the consultation, including the reason for the request, should be documented in the patient’s medical record.
    o   The treating/requesting physician/QHP may not report 99452 more than once in a 14-day period of time.
    o   Telephone, Internet, and/or electronic health record eConsults of less than 5 minutes should not be reported.
    o   Do not use the eConsult codes if the sole purpose of the communication is to arrange a transfer of care or other face-to-face service.

•      We concluded this consultation/education session by discussing how these specialized physicians could market their services, share their expertise, and be remunerated for their work. By the end of the teleconsultation, all of the physicians understood which consultation services and codes were payable by Medicare. Because all of their consultations are non-face-to-face, they were very enthusiastic about this opportunity.  

Summary

Physicians with chronic ulcer management expertise can share their expertise with other physicians/QHPs who need their assistance 1) to assess a particular patient and 2) to offer an opinion and/or treatment advice. If a non–face-to-face interprofessional consultation is conducted entirely via telephone, Internet, and/or electronic health record, both the requesting and the consulting physicians should report the codes described above. All of the codes are payable by Medicare. Most important, the consulting physicians do not have to interrupt their schedules; they can handle these non-face-to-face consultations at times they designate for consulting work.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.

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Reference
 
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