Some carriers want unlisted code in place of low-level consults

Why This Topic Matters

Practices need payer-specific guidance to avoid claim denials and to know whether a service should be reported under hospital E/M categories or handled according to a payer’s consultation policy. The article also highlights that private payer behavior may differ from Medicare, making plan-by-plan verification important.

Article Sections

1. Hospital consultation reporting after Medicare payment changes

   Discusses the shift in Medicare policy for consultation-related services and the resulting uncertainty for hospital-based reporting. Summarizes how local contractors were handling the issue.

2. Carrier and MAC policy approaches

   Reviews how selected Medicare contractors and carriers were treating these services, including differences in their preferred reporting approaches. Notes that policies were not uniform across payers.

3. CMS guidance and documentation considerations

   Summarizes CMS messaging about reporting visits based on setting and service complexity, along with related documentation expectations. Includes practical guidance on supporting claims when payers require additional reporting.

4. Private payer consultation policies

   Covers how some commercial insurers and Medicare Advantage plans were responding to the consultation payment changes. Highlights the need to check individual payer and state association resources.