Is a Consultation Still Coded as a Consultation?

So you are a specialist in year 2010 and a patient is scheduled for an office consultation. How are you going to code and bill for this service? The answer is "that depends"!

The Centers for Medicare & Medicaid Services (CMS) has finalized the calendar year 2010 outpatient and physician final rules, published in the November 20, 2009, and 25, 2009 Federal Registers. 2010 is going to be a year of many changes for specialist, especially in regards to billing Consultations services to Medicare patients. As part of the 2010 Final Fee Schedule Rule, Medicare has indicated that it will no longer pay for services coded as Consultations as of January 1, 2010.

The following are some frequently asked questions regarding coding and billing for Consultations:

Question: Which office and hospital codes should I use?

Answer: CMS has indicated that physicians should use the initial hospital visit codes (99221 - 99223) for services that are provided as consultations in the hospital setting and new or established office codes (99201 - 99205 and 99212-99215) in the office setting.

Question: Aren't initial hospital visits restricted to use by the admitting physician?

Answer: Yes, currently the initial hospital visit codes are restricted to be used by the admitting physician. Admitting physicians will append modifier "AI" (principal physician of record) to distinguish the admitting physician from other providers providing specialty care. Subsequent care visits by all physicians and qualified NPP's will be reported as subsequent hospital care codes (99231 - 99233).

Question: Is there a crosswalk of the consultation codes to the office and hospital codes?

Answer: Crosswalk's are generally used when a code is deleted. Use of Consultation codes have only been eliminated from Medicare, so the codes have not been deleted from CPT (Current Procedural Coding). Physicians should select the level of hospital or visit codes based on the documentation guidelines that are found in the evaluation and management section of CPT.

Question: Can I code and bill Consultations on patients with private insurance?

Answer: Other payer's may or may not adopt this policy. It is highly recommended that you contact your major payers to obtain instructions on how to bill.

Question: How do I bill if Medicare is a secondary payer?

Answer: If Medicare is secondary, it is highly recommended that evaluation and management codes should be used when billed to Medicare, otherwise the payment will be denied for invalid codes.

Question: Who will benefit from the elimination of the Consult Codes?

Answer: It has been projected that Primary Care rates for E&M services will increase by 5 - 8%. Specialist on the other hand will see a decrease in reimbursement. CMS affirms that its goal is not to increase or decrease payment for any particular specialty. CMS believes that all physicians will benefit from the budget neutral increase in the payment levels of the evaluation and management codes.

The RVU's (relative value units) used to pay for physician services, primary care RVU's will increase January 1, 2010. Hospital-based and freestanding physician practices that predominantly provide primary care services should verify that their charge structures are appropriately adjusted to exceed the Medicare fee schedule so that their reimbursement is not limited by their actual charge. They should also check with third party payers are paying based on Medicare RVU's.

There are numerous other provisions in these rules that will affect Medicare billing and payment for outpatient, ambulatory surgery centers and physician services.

With all of the Medicare changes, how is your practice going to survive? These are questions many physicians are asking. You may want to contact your CPA, Healthcare Consultants, and Network Provider Representatives to help you with strategic planning, provider, staff and patient education, overhead reduction and reimbursement updates.

This article was furnished by Linda L. D'Spain, CMPE, CMC, CMIS, CMOM. Join Linda in the January 27 Webinar, "Introduction to Revenue Cycle Management."

For more on the elimination of Consult Codes, join Regina Mixon Bates, IRO, TPA, CPC, CPC-I, CMC, CMIS, CMOM, for EM Visit Codes, during the January 21 Webinar. Regina will explain the new requirements and how to best adapt to this Medicare change.