Effective for claims with dates of service on or after Oct. 1, 2017, UnitedHealthCare (UHC) plans to no longer reimburse consultation services represented by CPT codes 99241–99245 and 99251–99255. In lieu of a consultation services procedure code, UHC says it will “reimburse the appropriate evaluation and management (E/M) procedure code which describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care reported,” as noted in UHC’s June 2017 Interactive Network Bulletin.
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Citing alignment with the Centers for Medicare and Medicaid Services (CMS), which discontinued reimbursing for consultation services in 2010, UHC noted in the June 2017 bulletin that this decision was made because “extensive data analysis has revealed misuse of consultation services codes for this population.”
The ACR strongly opposes this policy change and has serious concerns about the impact of this decision on the rheumatology community, because rheumatologists are cognitive subspecialists who are often asked by primary care providers to address patients’ most challenging and complex medical problems.
The ACR has started, and will continue, dialogue with UHC on why the work required to address these complex problems goes well beyond that required for a new patient visit, and why cognitive subspecialists, including rheumatologists, should be appropriately reimbursed for this service, says Sean Fahey, MD, a rheumatologist in Mooresville, N.C., and chair of the ACR’s Insurance Subcommittee.
Dr. Fahey plans to continue providing the same level of care to his patients, but he says this policy change does present challenges, namely with regard to preserving patient access.
“Historically, a consultation has required [a lot of] behind-the-scenes work—reviewing records, formulating a differential diagnosis, ordering and interpreting test results and coordinating a plan. This was compensated at a higher rate than when assuming care for a new patient with an established diagnosis,” Dr. Fahey says. “The fear is [that] if the reimbursement doesn’t match the work involved, complex patients will be squeezed out, and their care/diagnosis will be delayed as a result.”
In looking at the long-term impact of this policy change, Dr. Fahey and the ACR are concerned that other commercial payers may follow UHC’s lead and also discontinue appropriate reimbursement for consultation services.
Through collaborative work with other physician groups and with patient advocacy organizations, the ACR plans to continue efforts to ensure reimbursement matches services, particularly for rheumatologists as cognitive subspecialists with advanced training.
In a Sept. 5, 2017, letter to UHC, with a total of 27 state and local rheumatology societies signing on, the ACR stated that, “Failing to acknowledge the difference in work between a consultation and the relative simplicity of assuming the care of a patient with a known diagnosis is misguided and will predictably limit the ability of providers to consult on these complex cases.”