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BCBSM Will Cease Payment on CPT Consultation Codes for Medicare Plus Blue PFFS and Medicare Plus Blue PPO

Beginning July 1, 2010, Blue Cross Blue Shield of Michigan (BCBSM) will cease payment on CPT consultation codes for Medicare Plus Blue PFFS and Medicare Plus Blue PPO. This decision follows after the Centers for Medicare & Medicaid Services (CMS) discontinued reimbursement as of January 1, 2010 for consultation codes in CPT ranges *99241-*99245 and *99251-*99255.

BCBSM outlined three situations in which consultation codes will not be payable, beginning with dates of service on or after July 1, 2010:

  • Services performed in various settings that were previously billed to inpatient facility and office or outpatient settings.
  • Method II critical access hospitals, when physicians and non-physician practitioners have reassigned their billing rights.
  • In Medicare secondary payor cases, physicians and others must bill an appropriate evaluation and management code for the services previously paid using the consultation codes.
  • Where appropriate BCBSM will process consultation codes with dates of service on or after July 1, 2010, according to the following situations:

  • Claims billed with office or outpatient setting with CPT codes *99201-*99215, depending on the complexity of the visit and whether the member is new or established patient to that physician.
  • Claims billed with an inpatient hospital or nursing facility setting for any physician or qualified NPPs who perform an initial evaluation during an inpatient hospital care visit with CPT codes *99221-*99223 or nursing facility care visits with CPT codes *99304-*99306.
  • Hospital outpatient observation claims with CPT codes *99217-*99236.
  • Rural health clinic and federally qualified health center claims with CPT codes *99281-*99285 and *99304-*99306.
  • Emergency department claims with CPT codes *99281-*99288 for services provided to the member by both the member’s personal physician and emergency department physician.
  • Modifer “AI,” when billed with the evaluation and management, will distinguish the provider who oversees the member’s care from all other physicians who may be furnishing specialty care.
  • For more information on proper billing practice or assistance with BCBSM audits and appeals, please visit or contact a Wachler & Associates attorney at 248-544-0888.

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