Updated 3/23/10

Are Your Consultation Services Claims Being Denied by Your Local Medicare Carrier?

The Centers for Medicare and Medicaid Services (CMS) discontinued use of consultation service codes 99241-99245 and 99251-99255 performed in the office and hospital setting beginning January 1, 2010. This change means that patients referred to an electrophysiology (EP) office for a consultation must be reported using an Evaluation and Management (E/M) code for a new or established office visit (99201-99215) that most appropriately describes the level of service provided. In order to help our members with the transition, the Heart Rhythm Society created a list of frequently asked questions and resources. With the use of E&M codes to reflect consultation services, are you experiencing claims denials by your local Medicare carrier — especially when a general cardiologist and electrophysiologist from the same group practice bill E&M services provided on the same day or during the same hospitalization?

In the past, some local Medicare carriers have denied claims for EP services, citing duplicate billing, when a general cardiologist and an electrophysiologist from the same group practice billed consultation services provided on the same day or during the same hospitalization. This was true even when the services had clearly distinct diagnosis codes. If you are still experiencing this problem with the implementation of the new structure using the E&M codes, the Society asks you to complete a short, two-question survey to help us better understand this new dynamic.

One way to differentiate services provided by a general cardiologist and an electrophysiologist is to update the Health Care Provider Taxonomy Code on your National Provider Identifier (NPI) form by using the taxonomy code specifically for electrophysiology. This may also avoid claim denials in these instances.

What is the Taxonomy Code?
The Health Care Provider Taxonomy Code (HPTC) set, also referred to as Specialty Codes, is an external, 10-digit alphanumeric non-medical data code set designed for use in an electronic claims environment to classify health care providers according to provider type, classification and area of specialization.

Heart Rhythm Society members certified in clinical cardiac electrophysiology through the American Board of Internal Medicine (ABIM) should select taxonomy code 207RC0001X — Clinical Cardiac Electrophysiology as their primary**. This code is listed under "Internal Medicine."

If you meet the qualifications to use the electrophysiology code, designating this code on your NPI form will also be helpful in the Society’s work with CMS when differentiating the consultation services of EPs from those provided by general cardiologist.

» Download additional information on the taxonomy code and how to change your primary (PDF, 48K)

**Taxonomy codes are not “assigned” to health care providers; therefore, it is important that you select the taxonomy code(s) that most closely represents your education, license, and certification. Electrophysiology is a distinct subspecialty of cardiology, with considerable clinical differences that distinguish it from general cardiology. Also, if a health care provider has more than one taxonomy code associated with it, a carrier or health plan may prefer that the provider use one taxonomy code over another when submitting claims for certain services.