Medicare Stops Coding for Consults: What to Do Now?

Elizabeth Woodcock, MBA, CPC


December 15, 2009

The announcement that Medicare will no longer pay for consultation codes shocked the medical industry, leaving doctors worried about their income and perplexed about how to handle the new situation.

The change will certainly affect specialists who rely on the payment differentials -- 20%-30% -- between visit and consult codes. To offset the elimination of office consult payments, the Centers for Medicare & Medicaid Services (CMS) will increase the work relative value units (RVUs) for new and established office visits by about 6% and the work RVUs for initial hospital and facility visits by approximately 0.3% to reflect the elimination of the facility consultation codes.

To explain the controversial move, CMS pointed to physicians' problems in complying with Medicare's consult code guidelines.

The agency's Federal Register entry cites a 2006 Office of the Inspector General report, based on Medicare claims, that concluded: "Approximately 75% of services paid as consultations did not meet all applicable program requirements (per the Medicare instructions) resulting in improper payments."

Perhaps too late, the American Medical Association (AMA) has clarified the 2 circumstances under which doctors may render consultations. The circumstances, according to the AMA, are: (1) to "recommend care for a specific condition or problem," or (2) to "determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem."

In 2010, if you perform a consult in the office, choose an office visit code -- new (99201-99205) or established (99211-99215). In the hospital, the code selection process gets a bit more interesting. Consider that opinions are sought for many hospital patients, and those services have long been coded as consultations. This will change in 2010 for Medicare patients. CMS states that "physicians will bill an initial hospital care or initial nursing facility care code for their first visit during a patient's admission to the hospital or nursing facility in lieu of the consultation codes these physicians may have previously reported." This will be the case even if someone else admitted the patient.

From a coding perspective, admitting a patient could get tricky. CMS will create a new modifier for admitting physicians to append to the Current Procedural Terminology (CPT®) code: The modifier will be used to identify the admitting physician of record for hospital inpatient and nursing facility admissions. "This modifier will distinguish the admitting physician of record who oversees the patient's care from other physicians who may be furnishing specialty care."

The admitting physician of record will be required to append the newly created specific modifier to the initial hospital care or initial nursing facility care code, which will identify him or her as the admitting physician of record who is overseeing the patient's care. As for subsequent visits, CMS explains: "Subsequent care visits by all physicians and qualified NPPs [nonphysician providers] will be reported as subsequent hospital care codes and subsequent nursing facility care codes."

CMS will continue to recognize the consultation codes in the 2010 Resource-based Relative Value Scale (RBRVS). However, the payment codes are now marked with the status "I," meaning, "Not valid for Medicare purposes. Medicare uses another code for the reporting of, and the payment for, these services."

Because these codes have RVUs, it's possible that private insurers won't follow CMS's direction, and will continue to reimburse you for a consultation. Unfortunately, it's up in the air, so no one knows. One scenario is that insurers will pay in 2010 but will phase out reimbursements the following year. Whatever occurs in the future, it's in your best interest to confirm whether the commercial payers with which you participate will recognize these codes starting January 1, 2010.

After this change, specialists should make extra certain to:

  • Know when patients are "new" and when they're not, in order to retain the extra payment you receive for treating new patients;

  • Budget for the inevitable revenue decline; look for ways to watch cash flow and tackle office overhead;

  • Determine how you'll code consults for commercial vs government payers (you'll need to find out what your payers are advising about which set of codes to use -- the consult codes, as you have coded in the past, or the visit codes, as CMS is instructing you to use to get paid); and

  • Be on the look out for the new modifier that CMS says will be needed for hospital admissions.

Specialists who regularly used consultation codes may take quite a hit. It's critical to get prepared for this major coding change to avoid claim denials and missed opportunities. With the elimination of consult codes and all the other challenges out there, the last thing you need is a spike in claims denials.

Read more about consult coding in "Good-bye to consult codes: a blow to primary care and specialists alike?" at The Kane Scrutiny: Money and Medicine.


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