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.
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