Breaking: UnitedHealthcare Appears to Delay Eliminating Consultation Codes

More than three dozen advocacy groups appear to sway position of one of the nation’s leading carriers.

In the June 2017 UnitedHealthcare (UHC) Bulletin, it was indicated that the carrier would no longer cover consultation services within the evaluation and management (E&M) service codes, effective Oct. 1, 2017. UHC noted that it was going to be aligning its policies on these services with the interpretations of the Centers for Medicare & Medicaid Services (CMS) formally published and implemented seven years ago.

It is interesting that UHC noted that since CMS implemented this, it had been trying to pursue “data analysis and trending” of these services to make official policy updates. Well, apparently seven years of that was just not enough, as UHC has released its October 2017 bulletin, which notes that it is delaying this policy change:

“We previously announced that certain revisions to the Consultation Services Reimbursement Policy would become effective for UnitedHealthcare Commercial members on Oct. 1, 2017. In an effort to give care providers more time to adjust to potential changes in their submission of procedure codes for consultation services, UnitedHealthcare will be delaying implementation of the revisions to the Reimbursement Policy for services reported with consultation codes 99241-99245 and 99251-99255.”

It is important to note that UHC is not rescinding its decision, but merely delaying at this time.

So, why the change of heart? It is not often that a commercial carrier’s opinion on published guidance will be swayed by that of physician advocacy groups, but just maybe that is what happened here. Two weeks ago, we began to hear a hum from those “in the know” that UHC would delay this policy. Who were they? Thirty-seven physician advocacy groups, including medical and specialty societies, banded together and created a group letter to UHC opposing its decision.

The letter cited reasons UHC should reconsider the ousting of consults, as well as an appeal for UHC to publish the “data analysis and trending” of incorrect coding and use of consult codes, which UHC studied for more than seven years. Solid points presented by these 37 advocacy groups included (but are not limited to):

  • Hurdles that may prevent patients from receiving specialty care. Consult services should be those through which a provider requests the opinion of another provider, which more commonly than not would be that of a specialist. When CMS eliminated consult codes from reimbursable services, they increased the RVU of other E&M code categories in an effort to create an environment of stable reimbursements for providers. In the advocacy group letter, UHC was asked if it is making the same such RVU considerations. Keep in mind that just because a carrier deems consults a non-reimbursed service, this does not mean that the medical indications for a consultation go away. Consults are a fundamental requirement for continuity and coordination of patient care, and therefore a necessary part of healthcare.


  • The letter addressed the need for education or guidance on confusing policies. Not all UHC providers accept Medicare patients, and therefore some would not be educated on the CMS policies associated with the non-use of consult services and cross-walking of these codes to other reimbursed services. Therefore, education and published guidance should be provided by UHC to ensure the accuracy of reporting these services.


  • Aberrant changes to coding trends of specialist providers. As mentioned earlier, just because consults may not be reimbursed by the payer, this does not eliminate the medical need for consult services. Therefore, these services could (or should) be billed with other E&M services, thus affecting the coding trends for many providers. We all know that we live in a world of healthcare data mining, so these shifts in coding trends must be anticipated and not lead to needless additional audits.


  • The letter concludes by requesting that UHC rescind its policy, but at the very least consider a delay in implementation.

So, in as much as what was addressed in this letter to UHC (dated July 27, 2017), we now find that UHC is in fact delaying its policy. The notice does not indicate how long it will delay implementation. One could assume that with any associated annual updates to physician fee schedules and annual coding updates, this issue may be part of the carrier’s 2018 updates, but again, UHC has announced no further implementation dates at this time.

While there is nothing published indicating that the delay is a direct reaction to the cited letter, it seems quite plausible that it was. From this physician advocate to a bonded group of 37 advocate organizations who took on the carrier toe-to-toe, I humbly offer my gratitude.

However, I also offer that same gratitude to UHC as well for acknowledging serious considerations of new guidance, and delaying implementation in an effort to make adjustments, education, and modifications to ease such a transition.

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Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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