No More Consults? CMSs Proposal for 2010

January 30th, 2010 - Codapedia Editor
Categories:   Coding   Medicare   Medicare Physician Fee Schedule (MPFSDB)   Primary Care|Family Care  
0 Votes - Sign in to vote or comment.

July, 2010

By now you've seen the headline!  CMS proposes to eliminate payment for consults in 2010!  Why?  How will they pay for the services?

First, the AMA develops and owns CPT® codes, and only they can add, delete, or change the definition of CPT® codes.  However, Medicare and private payers develop reimbursement policies, and each payer can and does set their own payment rules.  Medicare, in particular, tends to take the lead and other payers adopt their policies, for better or worse.

CMS (the Center for Medicare and Medicaid Services) develops and proposes policies for physician payment each year in their Proposed Physician Fee Schedule Rule, released in the summer of each year, and in their Final Physician Fee Schedule Rule, released in the fall of each year.  There is an article about the Physician Fee Schedule in the Codapedia encyclopedia.

In July of 2010, CMS's Proposed Rule contained a real bombshell.  They proposed to stop paying for the consults, and increase the RVUs for new and established patient visits, and initial and subsequent hospital visits.  Why?  CMS believes that physicians have never understood properly the issue of transfer of care.  The Proposed Rule starts with a historical look at the consult codes, including CMS and AMA changes and revisions, as well as discussion of the OIG's 2006 report, which indicated that Medicare allowed approximately $1.1 billion more in 2001 than it should have, for services billed as consults.  The OIG report determined that approximately 75% of services paid as consults didn't meet all of program instructions. (level of care, didn't meet the definition of a consult, lack of documentation.)

In addition, CMS doesn't feel that the AMA has helped them in defining a transfer of care.  Here are a few quotes, "However, there remained discrepancies with unclear and ambigous terms and instructions in the AMA CPT® consultation coding definition..." and "There is an absence of any guidance in the AMA CPT® consultation coding definition that distinguishes a transfer of care service..."

The CMS proposal is to stop paying for these codes.  On an outpatient basis, primary care and specialty physicians would bill new or established patient visit codes, and the RVUs for these would increase 4-6%.  This would clearly benefit physicians who now bill more office visits than consults, and would be a revenue decrease for those physicians who currently bill more consults than new or established patient visits. 

For inpatient services, CMS would increase the RVUs for initial and subsequent hospital visits by about 2%.  All physicians would use the initial hospital visit codes (which do not have the word admission in their CPT® description) for their first visit with the patient during an inpatient stay.  The admitting physician would use a modifier to indicate that their visit was the admission.  (This would work be a benefit for hospitalists, who currently cannot bill consults for their first visit when managing the medical problems of post op patients.)

This rule is in the comment period right now.  That is, anyone can comment to CMS until the end of August about this proposal.  CMS will finalize the rule for 2010 in the Fall.

One complication:  the AMA does not have time to remove or change any codes for the 2010 book as of now, if they agreed with the policy, which seems unlikely.

CMS often proposes changes in the Proposed Rule, which do not become effective that year.  They tend to reappear in the proposed rule the next year, and are then implemented.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.
OIG Investigates SCAN Health for Risk Adjustment Overpayments With Surprising Results
July 26th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We’ve seen a number of OIG risk adjustment data validation (RADV) audits recently where the independent review contractor was simply looking for any codes the payer reported that were not supported by the documentation, in an effort to declare an overpayment was made and monies are due to be repaid. However, it was refreshing to read this RADV audit and discover that the independent review contractor actually identified HCCs the payer failed to report that, while still resulting in an overpayment, was able to reduce the overpayment by giving credit for these additional HCCs. What lessons are you learning from reading these RADV audit reports?
Addressing Trauma and Mass Violence
July 21st, 2022 - Amanda Ballif
After events of mass violence, it’s easy to feel helpless, like there is little we can do. In fact, we can help individuals, families, and communities build resilience and connect with others to cope together. The SAMHSA-funded National Child Traumatic Stress Network has developed a range of resources to help children, families, educators, and communities including the following which you can access via links in this article.
The 'Big 2' HIPAA Rules Medical Billing Companies Must Follow
July 20th, 2022 - Find-A-Code Staff
HIPAA covers nearly every aspect of how medical and personal information is collected, utilized, shared, and stored within the healthcare industry. Title II of the rules is applied directly to medical billing companies and independent coders. The 'Big 2' rules that medical billing companies must adhere to revolve around privacy and security.
The Beginning of the End of COVID-19-Related Emergency Blanket Waivers
July 19th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
It appears that the end of the 1135 waivers related to the COVID-19 public health emergency (PHE) has begun. According to CMS, the residents of skilled nursing facilities, long-term care facilities, and inpatient hospice centers have struggled due to the effects of some of the 1135 waivers. CMS is focusing primarily on removing the 1135 blanket waivers that pertain to certain aspects of care, training, and maintenance of these facilities to ensure the weakest of our citizens are guaranteed adequate care.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association