MEDAC BILLING & COMPLIANCE ALERT
November 6, 2009

CMS Eliminates Consults
By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

For decades, coding professionals and consultants alike have tried to educate physicians about the proper use of the consult codes.  The fact is, many healthcare providers, across all specialties have not properly utilized these codes and as a result, they have been a significant cost burden for CMS.  As reported on Wednesday, November 4 in the MGMA Washington Connection, in an effort to curtail its cost, “in the 2010 Medicare Physician Fee Schedule, CMS has eliminated the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for tele-health consultation G-codes)”.  

In an effort to calm providers on the elimination of consults, CMS has increased the work RVUs for new and established patient visits.  They have also increased the work RVUs on initial hospital and nursing facility visits, and have made adjustments for the increased use of these codes into the practice expense and malpractice RVU calculations.

Will this decrease your revenues?

With the elimination of payment for consults, CMS has stated that they have increased the work RVUs, practice expense RVUs and malpractice RVUs on the codes that will be utilized in place of the consult codes.  Does that mean you will make more or less money?   
Well, I did a comparison of the RVUs for the codes that will be used in place of the New Patient Office/Outpatient Consultation Codes (99241 – 99245).  The codes that will be utilized in place of the New Patient Office/Outpatient Consultation codes are the New Patient Office/Outpatient Visit codes (99201 – 99205).  The comparison shows that although CMS increased the RVUs on these New Patient Visit codes that will replace the New Patient Consultation codes, the RVUs are still not as high as they were on the old Consultation codes:

2009 Consult RVUs:   Hosp / Ofc 2010 Visit RVUs:  Hosp / Ofc

99241     0.92  /  1.35                                99201     0.72  /  1.12
99242     1.94  /  2.52                                99202     1.39  /  1.96
99243     2.70  /  3.46                                99203     2.11  /  2.83
99244     4.27  /  5.11                                99204     3.59  /  4.39
99245     5.33  /  6.28                                99205     4.61  /  5.47

As evidenced above, although CMS increased the RVUs on the Visit codes (99201 – 99205) they still lower than the RVUs on last year’s (2009) consult codes (99241 - 99245).  So what does this mean?  This means that if you are a chronic pain practice, and if your consult utilization was higher than your visit utilization, your practice will generate less money for these services than you did last year.

So what about non-Medicare payers?  Can you bill consult codes to these payers?  What will happen if Medicare is secondary?  Well, first of all the codes for consults have not been deleted from the 2010 CPT manual.  Therefore, one must wonder if the consult codes can still be billed to non-Medicare payers.  The answer is yes - - until and if the non-Medicare payers do not follow suit with Medicare.  But, what do you do if you bill a consult to a non-Medicare primary payer, but Medicare is your secondary payer?  Well, Medicare is going to deny the secondary payment.  What happens if Medicare is primary but you have a secondary payer that will allow you bill for a consult?  Well, I believe this truly will depend on how the payers want us to handle it.  Obviously we are going to have to accommodate this scenario and I have notified our IT department of this issue.

Is there anything good that will happen for providers as a result of this change?  Well, one good thing is you don’t have to worry about meeting those burdensome documentation requirements for a consult:  (1)  A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source; (2) A request for a consultation from an appropriate source and the need for the consultation must be documented in the patient’s medical record; (3) After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

Consequently, with the elimination of these consult codes, most providers will be billing more transfers of care (CPT codes 99201 – 99205 and 99211 – 99215).  A transfer of care occurs when the referring physician transfers the responsibility for the patient’s problem to a receiving physician at the time of referral, and the receiving physician documents approval of care in advance. The receiving physician would report/bill a new or established patient visit depending on the situation (a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years) and setting (e.g., office or inpatient).   

Inpatient consults (CPT codes 99251 – 99255) are another story.  What codes will be utilized for New patient, inpatient consults?  Well, it would seem that the apparent choice would be the Initial Hospital care codes (CPT codes 99221 – 99223).  However, the guidelines for these codes specifically state:  “these codes are used to report the first hospital inpatient encounter by the admitting physician.  For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251 – 99255) or subsequent hospital care codes (99231 – 99233).  Since the inpatient consult codes (99251 – 99255) have been eliminated by CMS and the initial hospital care codes (99221 – 99223) are only for use by the admitting physician, it is my assumption that you will have to utilize the subsequent hospital care codes (99231 – 99233) in place of the new or established inpatient consult codes.  The RVUs on the subsequent hospital care codes are lower than those associated with the inpatient consult codes and will also lead to a decrease in revenues for these services.

You my read the entire Medicare Physician Fee Schedule in its entirety at www.cms.hhs.gov, key word search 2010 Medicare Physician Fee Schedule.  I will keep you posted on any updates or changes to the 2010 Medicare Physician Fee Schedule

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.