Has anyone entered into a contract with private payors for to pay for eConsults (99446-99449)? The codes are Status Indicator B (bundled Medicare) for which no separate payment is made. As Medicare never reimburses for them, there is no need to issue an ABN or bill to Medicare with a GA modifier. The last Phys Fee discussion I could find in the Federal Register was for CY2016 where comments had been collected, encouraging CMS to pay for the services. In review of the Fee Schedules, the 2014 Fee Schedule did not value the codes with wRVUs; whereas the 2018 fee schedule values the codes. As with CPT 99091, it appears that CMS is moving towards reimbursing for these codes – but not just yet.
The benefits to a payer in paying for a physician to physician eConsult are obvious: lower costs for the contracted payer as the primary care physician does not refer to specialty care, while it assists in maintaining access for higher acuity patients to specialty care. In addition, timely advice to a primary care provider potentially decreases the exacerbation of a condition with resulting higher costs – to the payer. As this code is never reimbursed by Medicare, we should not be obligated to charge other patients whose insurances do not cover these services. It was mentioned in the Federal Register that there should be no liability to the patient because "beneficiaries could be responsible for coinsurance for services of physicians whose role in the beneficiary’s care is not necessarily understood by the beneficiary."
https://www.federalregister.gov/docu…ther-revisions
Thanks!
Carol Yarbrough, MBA, CPC, CHC, CCA, OCS
UCSF Medical Center