Medicare Eliminates Consult Codes; What your Practice Needs to Prepare

By Dena Mallin, CPC

Major changes are around the corner. CMS (Centers for Medicare and Medicaid Services) announced the elimination of consult codes. Officially released and documented in Change Request “CR 6740”as of January 1, 2010 consult codes will be eliminated from the Medicare fee schedule.  Medicare will no longer recognize or pay for services billed with consult codes 99241-99245 or 99251-99255.  However, as I am editing this article, Senator Arlen Specter (D-PA) has put forth an amendment to delay for one year CR6740.  There has been no action on his proposed amendment and there is no certainty as to the outcome. Your practice should be prepared for the change as it significant.

2010 will be a year of confusion with practices and payers adapting to this change. While CR6470 impacts only Medicare claims as of January 10^th 2010 we expect private payers to follow in suite. As things sit today, Medicare claims will not use consult codes, while the private payers will. Confusion is a coming and many scenarios do not have clarity today. Key to minimizing the financial impact of this change will be the verification of patient insurance prior to the physician visit. The provider must be made aware of a patient’s Medicare coverage in advance of coding and use the appropriate CPT code to bill for the service.

To receive proper reimbursement, providers must instruct their staff to monitor changes in insurance coverage carefully. Attention must be paid to the Medicare Advantage plans that are likely to follow the Medicare rules. To date there has been limited written communication from private payers. An unnamed IBC representative informed me their policy will be following the same path with Medicare plans, but there is nothing in writing. What will happen when a private payer is primary and Medicare second, unknown at this stage. Careful attention must be paid to payments, as that will give true indication.

In the Hospital Physicians who previously billed with a consult code will now use initial hospital codes of 99221-99223 when requested to see a patient. Attending physicians will append modifier “AI” to their initial visit so that Medicare can differentiate between attending visits and consulting physicians.

In the Nursing home physicians who previously billed using an inpatient consult code will now use initial nursing home codes of 99304-99306. The admitting or attending physician will append the “AI” modifier to their charge.

To summarize: All attending or admitting Physicians must append the “AI” modifier to their initial bill.

Emergency Room Physicians previously billing outpatient consults will use ER codes 99281-99285. These codes were previously designated for Emergency Room Physicians only.

In the office, physicians will use 99201-99215 for a new or established patient visit in place of consults. Physicians who bill many outpatient consults may see a significant revenue decrease depending on whether the patient is new to the practice or not.  To see the financial impact to your practice you must know whether the previous consults would meet the criteria as a new or established patient. The key is whether or not you can bill as a new patient visit. Remember a new patient is a patient who has not received a professional service from the physician or from other physicians of the same specialty in the same group in the past three years. Remember if you treat a patient in the hospital and then you or any member of your group treats that patient in your office, the patient is not considered to be a “new patient”.  RVU’s for new and established visits will be increased by 6%.

Documentation guidelines should be continued as normal with notations in the progress or chart note when there is a request for your opinion and recommendation. The only documentation change is the elimination of the requirement to send a written report as part of the coding guideline. While the rule has disappeared to send a written report, it is considered good communication and patient care to continue to communicate in writing to the requesting physicians.

There is no direct crosswalk in the coding guidelines. If you were previously billing a level 4 consult this does not automatically cross to a level 4 established patient. In many instances a level 4 inpatient consult may meet the requirements of a level two initial hospital or nursing facility but providers would be prudent to review the coding guidelines prior to January 1, 2010.

Providers should examine their operating processes to determine if charge capture forms have to be changed.

It is critical at this juncture for all providers to have their specialty designations correct as this is critical in determining if a patient is new or established in multispecialty practices.  If your specialty designation is not correct, you may update this through the CMS enrollment process.

Use the table below to help guide you through the change.

Confusion is sure to occur when the patient has Medicare insurance as secondary and private pay, as primary. The current assumption is; if a consult code is submitted to the private payer, then the claim going to Medicare as a secondary will have to be altered.  Close attention will have to be paid to how these claims are adjudicated.  Change Request “CR 6740” eliminates consult codes from the CMS 2010 fee schedule will surely cause confusion. There is no “cross-walk” solution for payer’s adjudication systems. Providers should monitor reimbursement and denials carefully for improper payment. As the year progresses additional clarifications will certainly materialize.

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Dena Mallin, CPC, is President of Claims Pro (www.claimspro.net) and can be reached at dena@claimspro.net or 215.732.7600 (x102).