Consult Code Update

 

Physician work RVU’s for new and established office visits will increase by 6% to reflect the elimination of the office consultation codes.  Initial hospital and facility visits will see a 2% increase in the physician work RVU’s as a result of the elimination of the facility consultation codes. CMS announced these changes will be budget-neutral, so as not to either increase or decrease aggregate expenditures under the physician fee schedule.  CMS will also adjust the practice expense and malpractice expense RVUs to recognize the increased use of these visits.  

 

CMS instructs physicians to use the initial hospital day and subsequent hospital day codes (99221-99233) for the in-patient setting and new and established E/M codes in the outpatient setting (99201-99215). 

 

Physicians and various specialty societies expressed concern to CMS and indicated it was burdensome to the requestor and consultant to provide the required written documentation for consultations.  Over the past five years, CMS and the AMA-CPT worked together in an attempt to improve guidance for consultations services.  Continued concerns resulted in the AMA deleting the in-patient follow-up consultation codes in 2006.  Issues related to the ‘transfer of care’ versus a ‘consultation’ resulted in this new change, effective January 1, 2010.  CMS also took into consideration the OIG report published in 2006 on “Consultations in Medicare: Coding and Reimbursement,” that indicated Medicare allowed approximately $1.1 billion more in 2001 than it should have for services billed as consultations.

 

Many of the commercial carriers have already given notice that they are following Medicare’s direction on this and will not accept the consult codes as of January 1st.  As of last week, Blue Cross and United Health went on record they will be following Medicare’s direction.  CMS advised that physicians will have to decide how to handle situations where Medicare is secondary, and the primary payer continues to recognize the consultation codes.  The agency made clear that it would reject any secondary claims billed with the invalid consultation codes and instead suggested that physicians could bill the primary payer using the visit codes.  The other payers may or may not allow the visit codes to be used when a consultation is furnished.  If they do, but fail to increase their payments for the visit codes as CMS did, physicians will see a decrease in reimbursement from the primary payers.

 

As a result of this change, a request for consult, patient referral or transfer of care will be treated the same for Medicare coding and billing purposes, as either a new or established patient. Physicians are strongly encouraged to continue documentation of the requesting physicians on all consults requests in the patient’s medical record. If the patient is new to you or your practice or hasn’t been seen in the past three years (36 months), the patient is considered a new patient.

 

To distinguish the admitting physician from other specialists who see the patient in the hospital and who will also use the initial care codes, CMS has assigned the modifier ‘A1’ for the admitting physician to add to the initial care codes to identify him/her as the admitting physician. All other physicians who see the patient in the hospital will bill the applicable initial care code without a modifier.