UPDATE CMS ELIMINATES PAYMENT FOR CONSULTS 1-1-2010

January 30th, 2010 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)   Medicare   Relative Value Units (RVUs/RBRVS)  
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Updated: Dec 16, 2009

By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims.  Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached.

For services that were outpatient consults, provided in the office and outpatient department, use new or established patient visit codes.  (99241--99245 will be 99201--99215).  Review the definition of a new patient from the CMS manual:

Interpret the phrase “new patient” to mean a patient who has not received any
professional services, i.e., E/M service or other face-to-face service (e.g., surgical
procedure) from the physician or physician group practice (same physician specialty)
within the previous 3 years.

Some patients, who would have been office/outpatient consuts will now be established patients.  The consult codes were not defined as new or established.  Specialty designation is critical, as well as the three year time period.  Remember that location is not a factor.  Whether the physician or the physician's same specialty partner saw the patient in the hospital or office doesn't matter in the specialty designation.

Admitting physicians must now use modifier AI (capital I, not number 1) on their claim forms to indicate they are the admitting physician when they bill for the admission, 99221-99223.  All other physicians who see a patient for the first time will also bill using the initial hospital services codes (what we call the admission codes 99221-99223).  CMS has instructed carriers to pay for multiple "initial" hospital services for the same patient, even if they are on the same day.  Remember, however, that physicians of one specialty in a group can only bill one of those/admission. The AI modifier needs to be attached only to the initial hospital services codes, not to the subsequent visits or discharge services.  However, CMS has instructed carriers to ignore the modifier if it appears on other line items during the admission.

How does a physician bill who is called to the ED to see a patient, who is not admitted?  Use the ED department codes (99281--99285).  Previously, these were billed with outpatient consult codes, if the criteria for a consult were met.  This means, physicians of multiple specialties will all bill ED codes on the same patient, on the same date of service, perhaps for the same diagnosis.  We can only hope that the Medicare Administrative Contractors will not deny these claims.

If a patient is in observation status, the admitting physician uses the OBS codes without a modifier, 99218--99220 or 99234--99236.  Other physicians who are called to see the patient should use office and outpatient codes, 99201--99215, keeping in mind the definition of a new patient visit.

Hospitalists will be able to bill the initial hospital services codes for their post-op evaluations, by my reading of this change request, for medically necessary, non-surgical management of medical problems.  Previously, they were limited to a subsequent hospital visit.  I will change the Codapedia article on that topic as well.

Written October 31, 2009

It's true!  They did it.  Starting January 1, 2010 CMS will no longer pay physicians if they submit claims with codes in the 99241--99245 or 99251--99255 series.  After years of struggling to differentiate a consult from another E/M service by using the concept of transfer of care, they've just said no.

This will be budget neutral to CMS, but not necessarily to your practice.  CMS has increased the RVUs for new and established patients by 6% and for initial and subsequent hospital visits by 2%.  Obviously, this will result in an income increase for primary care specialties, and a decrease for specialists who use consult codes.  The difference between a new patient visit and a consult was far greater than 6%.  Hospitalists will get a boost, however.  Read on to see how.

How will this work?  Any physician who sees a patient in the office will need to select either a new or established patient visit, depending on the status of the patient. (A new patient is a patient who has never received a professional service from that physician, or another physician of the same specialty, in the same group, inthe past three years).   That's fairly straightforward, as long as you remember the definition of a new patient.  Some specialists will end up billing established patients when they see a "referral" from a PCP, if the patient was seen in the last three years by one of their partners.

In the hospital, each physician who sees a patient will bill for an "initial hospital service" or what we in the physician community persist in calling "admissions."  The admitting physician will add a modifier to their initial hospital service, allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care.  That's a boon to hospitalists who could only charge a subsequent hospital visit for co-management with surgeons.  All physicians will use the subsequent visits for their follow up care.

The Final Rule describing this is about 100 pages long, describing the history of consults, the difficulty in defining the concept of transfer of care and a high error rate for the services when reviewed by the OIG.  CMS read the many  comments they received, responded,and in the end said, "Accordingly, we are adopting our proposal in this final rule."

What about other payers?  The consult codes are in the 2010 CPT® book, with new commentary about transfer of care.  We will have to query our commercial payers individually, to ask them if they are changing their policies.  In the meantime, we will have one set of rules for Medicare patients and one set for other payers--not a new experience.

We will have to consider what to do when Medicare is a Secondary Payer.  If the primary does not pay all of the charge, and it crosses to Medicare with the consult codes, it will be denied.

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