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.