UnitedHealthcare (UHC) recently proposed two policy changes that would have a negative impact on reimbursement for consultation services and evaluation and management (E/M) services when billed with modifier 25. The effective date for both of these proposed changes is Oct. 1, 2018.
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Consultation Services
Under the proposed consultation codes policy, UHC would end reimbursement for Current Procedural Terminology (CPT) codes 99241–99245 and 99251–99255. UHC announced a similar plan last year, but ultimately rescinded the policy after receiving outcry from a number of physician groups. As the ACR argued last year, the decision to end reimbursement for consultation services is misguided and would have a negative impact on physicians, especially the rheumatology community. Rheumatologists are often asked to provide consultations addressing patients’ most challenging and complex medical problems. This requires not only specialized experience and expertise, but also a significant amount of work, beyond that which is required for a new patient visit, and should therefore be appropriately reimbursed.
E/M Codes
A second policy change would reduce reimbursement for E/M services by 25% when billed with modifier 25. This plan is similar to a policy that was announced then rescinded by Anthem earlier this year. The ACR strongly opposes this change and believes that providers should be reimbursed appropriately and in accordance with the CPT coding guidelines when performing significant, separately identifiable and medically necessary E/M services on the same day as a procedure.
The ACR is engaging UHC directly and also coordinating with other specialty societies to voice opposition to these policies. For questions or more information, contact practice@rheumatology.org.