Bradford-Scott Medical

The decision to stop recognizing Current Procedural Terminology® (CPT) codes 99241–99245 and 99251–99255 in the Medicare program as of January 1, 2010, took many by surprise. In justifying its decision, CMS cited a 2006 Office of Inspector General report that 75 percent of consultations were billed incorrectly.

Offsetting the elimination of those payments, the codes CMS directs physicians to use instead received modest increases in the work relative value units (wRVUs). The small boost to units associated with these E/M codes, espouses CMS, means the decision to eliminate payment for consults is budget neutral for the Medicare program.

CMS’ exclusion of consultation codes for Medicare patients will certainly affect physician revenue, especially if private payers follow suit. Physicians must also devise new strategies for coding and documentation to continue getting reimbursed for seeing these Medicare patients, or else just decline to see them at all.

Here are answers to common questions physicians are asking about the new Medicare consultation policy:

How do I code consults for Medicare patients? 
Use the appropriate E/M code. For a patient in the hospital, code from the series CPT 99221-99223 for the initial encounter and 99231-99233 for subsequent encounter(s).

Can I ask the patient to sign an Advance Beneficiary Notice (ABN), and collect directly from the patient? 
CMS no longer recognizes the consultation codes as valid, as opposed to non-covered; therefore, you cannot use an ABN and bill the Medicare patient.

If physicians are directed to use the initial hospital visit code, how is an admission identified? 
To report an admission for Medicare, append AI (“a” – “eye”), the principal physician of record, to the initial hospital care code (99221-99223) or initial nursing facility care code (99304-99306). The new modifier is informational only; no additional remuneration is provided.

How will I get paid when a referring physician requests my opinion? 
CMS directs physicians to use the appropriate E/M code and will reimburse the physician even when services are requested within a practice within given parameters: “Medicare may pay for an inpatient hospital visit or an office or other outpatient visit if one physician or qualified NPP in a group practice requests an evaluation and management service from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.” Remember, this policy relates to Medicare, so you can continue using the consultation codes for non-Medicare patients.

Should physicians stop using consult codes altogether? 
It may be the easiest path from a process perspective but most payers, other than Medicare, continue to pay for consults. Because the payment differential is significant – consults pay up to 30 percent more than a visit code at the corresponding level – experts don’t advise dropping them altogether.

How do I handle Medicare as a secondary payer (MSP)? 
This may be the most confusing situation of all because CMS essentially authorizes you to change codes when it is the secondary payer. CMS instructs: “Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service [our emphasis], to Medicare for determination of whether a payment is due.” Develop processes for “crosswalking” codes on MSP claims, catching MSP claims before they are submitted to Medicare, and re-working any denied claims that miss your crosswalk process.

Does this policy change apply to Medicare Advantage plans? 
Medicare Advantage plans aren’t required to embrace the new payment policy, but some have. It’s important to check with the plans with which you participate.

Is it no longer necessary to send reports to referring physicians? 
Although it’s no longer necessary to follow CMS’ documentation rules specifically related to consults, CMS states: “…physicians should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting physician.” Furthermore, one of the proposed “meaningful use” criteria for the HITECH Act’s electronic health record bonus program is: “Provide summary care record for each transition of care and referral”.

How can I get more information?
Review the MLN Matters 6740: Revisions to Consultation Services Payment Policy.

In jettisoning consultation codes for Medicare, CMS cited audits showing high levels of inappropriate consultation coding, physician confusion about its rules, and its own disagreements with the consultation coding guidance in the AMA’s CPT® Manual. The new day for consultation coding is here. Let’s see how it works.

Written by Elizabeth W. Woodcock, MBA, FACMPE, CPC of Woodcock & Associates.

• Albany Obstetrics and Gynecology experienced 20% fewer missed appointments
• Patient information became increasingly more up to date
• Verifying coverage for patients reduced denied claims by as much as 70%
• The days in accounts receivable has been reduced to less than 30
• Phone nurses quickly accessed/updated information - relieving front desk congestion
• With EHR, paper charts aren't needed, saving over 3 hours per day in chart pulls
• Physicians are able to view patient information from outside the office

"It's invaluable that the physicians can look at patient records when they are on call, especially being able to see lab results,"

• Medicaid - When it comes to Medicaid, it is up to each state to determine how they will pay out the ARRA EHR stimulus money.  Sure, some will most likely try to keep it as to close to the Medicare model as possible, but we'd be silly to thing that some states wouldn't go in a completely different direction. 
• Medicare - The earliest that we'll see Medicare ARRA EHR stimulus money is in the spring of 2011.  Remember, you have to prove "meaningful use" of your "certified EHR" for a minimum of 90 days to receive the incentives.

1. Include a DUNS Number. A DUNS Number must be included in order for an application to be reviewed.  DUNS numbers can be obtained by accessing www.dunandbradstreet.com or by calling 1-866-705-5711. Include the DUNS number next to the OMB Approval Number, which is located in the upper right corner of the application face page.
2. Keep the audience in mind. Reviewers will use only the information contained in the application to assess the application. Therefore, the applicant should be sure the application and responses to the program requirements and expectations are complete and clearly written. Do not assume that reviewers are familiar with the applicant organization. Keep the review criteria in mind when writing the application. 
3. Start preparing the application early. If applying electronically through Grants.gov please ensure that adequate time is allotted to register and download applicable software and forms. Grants.gov offered a "Webcast" (registration required) entitled "Get Started with Grants.gov" that provides start-up requirements and tips.
4. Follow the instructions and application guidance carefully. The instructions call for a particular organization of the materials, and reviewers are accustomed to finding information in specific places. Present information according to the prescribed format.
5. Be brief, concise, and clear. Make each point understandable. Provide accurate and honest information, including candid accounts of problems and realistic plans to address them. If any required information or data is omitted, explain why. Make sure the information provided in each table, chart, attachment, etc., is consistent with the proposal narrative and information in other tables. 
6. Be organized and logical. Many applications fail because the reviewers cannot follow the thought process of the applicant or because parts of the application do not fit together. 
7. Be careful in the use of appendices. Do not use the appendices for information that is required in the body of the application. Be sure to cross-reference all tables and attachments located in the appendices to the appropriate text in the application. 
8. Carefully proofread the application. Misspellings and grammatical errors will impede reviewers in understanding the application. Be sure pages are numbered (including appendices) and that page limits are followed. Limit the use of abbreviations and acronyms, and define each one at its first use and periodically throughout application.

• Record important cardiovascular measurements
• Trend vital signs, symptoms, physical findings, ejection fraction, medications and laboratory results
• Easily add, change or renew medications and use medication "favorites" by diagnosis -- even track those issued by the primary care physician
• Set up clinical practice guidelines which provide reminders and orders sets for disorders such as coronary artery disease and congestive heart failure
• Reduce transcription costs by using structured documentation through encounter forms while preserving the flexibility to dictate part or all of the note
• Order and schedule common diagnostic tests like electrocardiogram (ECG), Cardiac Isotope Imaging (SPECT) and ultrasound
• Streamline documentation by using detailed templates for common cardiac conditions 
• Use health reminders and alerts for preventive treatments

• Improved Coding - With better documentation tools,your coding will be more accurate, leading to better reimbursements
• Storage - Keeping paper charts on-site takes up too much space and keeping them off-site takes up too much of your money.  
• e-Prescribing - Did you know that, on average, your staff spends 10 minutes handling prescription refill calls alone?  How many of these calls are they taking each day?  
• Malpractice Premiums - Some insurance carriers offer discounts to those providers using EHR.
• No More Chart Pulls - This one speaks for itself.  :)