# End of Consultation Codes?



## robo50 (Nov 9, 2009)

I've been hearing alot of chatter about Consultation Codes being eliminalted in 2010.  I did see something in print on the CMS website stating that CMS was preparing for this but it gave no details.  Is this going to happen and, if so, how will a tradiditonal consultative service be coded, both inpatient and outpatient?


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## Joette (Nov 9, 2009)

*Medicare eliminates payment for inpatient and office consults*

Yes, CMS is eliminating the payment for inpatient and office consult codes effective 1/1/2010. Other payers may or may not follow their lead. For Medicare what would have been an office consult will be billed as a new or established patient visit. For an inpatient consult those will be billed as the initial care inpatient or initial care nursing facility codes.  To distinguish the admitting physician service from other initial inpatient care the admitting physician will use a new modifier to be announced.


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## TamaraM (Nov 9, 2009)

Yes I have heard about this also through network however I have not been able to find documention for my docs. 

I work for a ortho specailist this is really going to hurt them. 50% of their work is doing consults and with out the extra $ i wonder how bad it's going to hurt this practice.


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## nc_coder (Nov 9, 2009)

Joette,
Can you tell us where you got your information from?  I looked on the Medicare website but cannot find this in writing.  It is so hard to find anything on the website unless you know exactly where to go.  
I have a meeting with the AR department this week and would love to be able to bring this information to them.
Thank you for your input.


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## RebeccaWoodward* (Nov 9, 2009)

For Immediate Release:
 Friday, October 30, 2009

Contact:
 CMS Office of Public Affairs
202-690-6145




CMS ANNOUNCES PAYMENT, POLICY CHANGES FOR PHYSICIANS SERVICES TO MEDICARE BENEFICIARIES IN 2010 

The Centers for Medicare & Medicaid Services (CMS) today announced final changes to policies and payment rates for services to be furnished during calendar year (CY 2010) by over 1 million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule (MPFS).  The MPFS sets payment rates for more than 7,000 types of services in physician offices, hospitals, and other settings.  Today’s action complies with federal law, which requires these policies and payment rates to be announced by Nov. 1.

Current law requires CMS to adjust the MPFS payment rates annually based on an update formula which requires application of the Sustainable Growth Rate (SGR) that was adopted in the Balanced Budget Act of 1997.  This formula has yielded negative updates every year beginning in CY 2002, although CMS was able to take administrative steps to avert a reduction in CY 2003, and Congress has taken a series of legislative actions to prevent reductions in CYs 2004-2009.  In the absence of Congressional action for the CY 2010 physician update, the final rule with comment period will reduce the conversion factor for services on or after Jan. 1, 2010 by 21.2 percent rather than the -21.5 percent projected in the proposed rule.  The difference is due to the use of the most recently available data on CMS spending for physicians’ services.

“The Administration tried to avert the pending fee schedule cut in the FY 2010 budget proposal that it submitted to Congress, and remains committed to repealing the SGR,” said Jonathan Blum, director of the CMS Center for Medicare Management.   “In the meantime, CMS is finalizing its proposal to remove physician-administered drugs from the definition of ‘physicians’ services’ for purposes of computing the physician fee schedule update.  While this decision will not affect payments for services during CY 2010, CMS projects it will have a positive effect on future payment updates.”

In the final rule with comment period, CMS is also adopting several refinements to Medicare payments to physicians which will improve payment rates for primary care services relative to other services.  For 2010, for purposes of establishing the practice expense (PE) relative value units (RVUs), CMS had proposed to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey (PPIS), designed and conducted by the American Medical Association.  CMS is finalizing the proposal, but will phase it in over a four year period.  In addition, CMS will not use the PPIS data to determine the practice expenses for  medical oncology, but instead will continue to use specialty supplemental survey data , as indicated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

*CMS is also finalizing its proposal to stop making payment for consultation codes other than the G codes that are used to bill for telehealth consultations, and to redistribute the resulting savings to increase payments for the existing evaluation and management (E/M) services.   CMS will adjust the payment for the surgical global period to reflect the higher value of the office visits furnished during the global period.*
In the final rule with comment period, CMS is adopting two significant modifications to its proposal to increase the equipment utilization percentage that is assumed for purposes of setting PE RVUs.  CMS will increase the equipment utilization rate assumption used to determine the practice expense for expensive equipment priced over one million dollars from 50 to 90 percent but will phase in this change over a four year period.  CMS also will not apply this change to expensive therapeutic equipment.

CMS is increasing payment for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services.   Originally established in the MMA, the IPPE benefit now pays for an initial assessment of key elements of a beneficiary’s health within one year of the beneficiary’s enrollment in Medicare Part B.

Taking all changes in the final rule with comment period into account, CMS projects that payments to general practitioners, family physicians, internists, and geriatric specialists will increase by between 5 and 8 percent, prior to application of the negative update required by the SGR.

The final rule with comment period also implements a number of provisions in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) including:

Adding new Medicare benefit categories for cardiac and pulmonary rehabilitation services and for chronic kidney disease (CKD) education beginning Jan. 1, 2010.   The final rule with comment period outlines what these programs will entail, how they will be paid under the MPFS and the criteria for covering these services.  
Increasing the Medicare share of payments for outpatient mental health services to 55 percent from 50 percent, beginning a gradual transition to bring payment parity for mental health and medical services furnished to Medicare beneficiaries.  
Implementing a requirement that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012.   The accreditation requirement will apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but will not apply to the physician who interprets them.  CMS will address suppliers’ accountability, business integrity, physician and technician training, service quality, and performance management through additional guidance.  
The final rule with comment period contains a number of provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program (e-Prescribing Program) and the Physician Quality Reporting Initiative (PQRI).  Specifically, the final rule simplifies the reporting requirements for the electronic prescribing measure, provides eligible professionals with more reporting options, and establishes a new process for group practices to be considered successful electronic prescribers.  Eligible professionals or group practices that meet the requirements of each program in CY 2010 will be eligible for incentive payments for each program equal to 2.0 percent of their total estimated allowed charges for the reporting periods. 

In addition, CMS is adding measures for eligible professionals to report under the PQRI, providing a mechanism for participants to submit quality measure data from a qualified electronic health record and creating a process for group practices to use for reporting the quality measures.

*The final rule with comment will appear in the Nov. 25, 2009 Federal Register.  CMS will accept comments on designated provisions of the final rule with comment period until Dec. 29, 2009, and will respond to all comments at a later date.  Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2010.*

To view a copy of the final rule with comment period, please see:

www.federalregister.gov/inspection.aspx#special

A fact sheet providing more information about the e-Prescribing Program and PQRI provisions can be found at:

www.cms.hhs.gov/apps/media/fact_sheets.asp

http://www.cms.hhs.gov/apps/media/p...ge=&showAll=&pYear=&year=&desc=&cboOrder=date


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## mmunoz21 (Nov 9, 2009)

Thank you, and this is effective for all Consultations office and hospital?


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## RebeccaWoodward* (Nov 9, 2009)

Yes...


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## robo50 (Nov 9, 2009)

I've seen the above posted CMS notice however, they do not state what the alternative is going to be to replace the Consut codes.  I strongly anticipate the solution that Joette stated above is how it will wind up but, it would be nice to see some official documentation to show our docs.


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## RebeccaWoodward* (Nov 9, 2009)

robo50 said:


> I've seen the above posted CMS notice however, they do not state what the alternative is going to be to replace the Consut codes.  I strongly anticipate the solution that Joette stated above is how it will wind up but, it would be nice to see some official documentation to show our docs.



The *plan* is....provider based/outpatient...New/Establish visit

Inpatient-Admission code.  The actual "attending physician" will have a designated modifier to indicate he/she was the admitting...


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## LTibbetts (Nov 10, 2009)

tamara818 said:


> Yes I have heard about this also through network however I have not been able to find documention for my docs.
> 
> I work for a ortho specailist this is really going to hurt them. 50% of their work is doing consults and with out the extra $ i wonder how bad it's going to hurt this practice.



Tamara, while it will make a bit of a difference in the revenue for the practice I am afraid, it appears that the E/M codes are going to be raised in value to help offset the dip in revenue coming in. It will be a big change but hopefully it will clear up a lot of confusion regarding consulting codes that a lot of people are having. Don't worry, after your providers stop stomping their feet and start to calm down a bit, it will all blow over, just as the new changes always do. Just keep reminding them that it is only Medicare for now, although, the others payors may soon follow suit but they don't need to hear that just yet, you know? Good luck and hang in there


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## RebeccaWoodward* (Nov 10, 2009)

In the absence of Congressional action for the CY 2010 physician update, the final rule with comment period will *reduce the conversion factor for services on or after Jan. 1, 2010 by 21.2 percent rather *than the -21.5 percent projected in the proposed rule....

I imagine this will effect more than just specialist...


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## aguelfi (Nov 11, 2009)

*Modifier?*

This is the first I've heard of a new modifier.  Where did you find documentation to support that.


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## RebeccaWoodward* (Nov 11, 2009)

Because of an existing CPT coding rule and current Medicare payment policy regarding the admitting physician, *we will create a modifier **to identify the admitting physician of record for hospital inpatient and nursing
facility admissions.* For operational purposes, this modifier will distinguish the admitting physician of record who oversees the patient's care from other physicians who may be furnishing specialty care. The admitting physician
of record will be required to append the specific modifier to the initial hospital care or initial nursing facility care code which will identify him or her as the admitting physician of record who is overseeing the patient's care. Subsequent care visits by all physicians and qualified NPPs will be reported as subsequent hospital care codes and subsequent nursing facility care codes.

http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf

Page 178


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## CrysLednum (Dec 17, 2009)

OK - so I just wanna get this straight.  The new Modifier AI is for the ADMITTING DOC - regardless of specialty.  I work for ortho and the attending will call our docs to consult and then our docs admit.  So I would append the AI?  

This is going to be terrible.  Has anyone heard about what to do when Medicare is Secondary?


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## codexpert (Dec 17, 2009)

robo50,

CMS put out a three page explanation regarding the consultation codes and payment policy on 12/14/09 MLN Matters# MM6740, CR Transmittal# R1875CP.  Hope this helps I have a printed copy in my hands.

~Roxanne


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## codexpert (Dec 17, 2009)

Forgot to tell you guys the modifier that will be used for the primary attending physician will be AI


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## GTRINIDAD (Dec 30, 2009)

Does anyone know how I would code an ER consultation by a Psychiatrist beginning 1/01/2010 for a M/C patient? 

We previously used 99241-99245 but now we're to use 99201-99215; how would this work considering the fact that the office/other outpatient codes are seperated by New and Established patient?...

Please advise.

Thanks,

Gloria T, CPC
New York


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## FTessaBartels (Jan 7, 2010)

*ER "consult" 2010*



GTRINIDAD said:


> Does anyone know how I would code an ER consultation by a Psychiatrist beginning 1/01/2010 for a M/C patient?
> 
> We previously used 99241-99245 but now we're to use 99201-99215; how would this work considering the fact that the office/other outpatient codes are seperated by New and Established patient?...
> 
> ...




You code the appropriate level ER visit based on documentation.

F Tessa Bartels, CPC, CEMC


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## MnTwins29 (Jan 8, 2010)

Only the ER physician can use 99281-85.  For ER consultations, either the outpatient or inpatient codes may be used, depending on if the patient is admitted or discharged from the ER.  

Also, there is still a possibility that the 21.2% reduction in the payment rate may be retracted.  The Senate HC reform bill had this language to repeal the SGR method of determining the conversion factor, which was the reason for the decrease.  If the compromise bill contains this amendment, the reduction will not take place.


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## MnTwins29 (Jan 8, 2010)

CrysLednum said:


> OK - so I just wanna get this straight.  The new Modifier AI is for the ADMITTING DOC - regardless of specialty.  I work for ortho and the attending will call our docs to consult and then our docs admit.  So I would append the AI?
> 
> This is going to be terrible.  Has anyone heard about what to do when Medicare is Secondary?



Check out this document from MLN - MLN Policy #JA6740.  Basically, if MCR is secondary and the primary payer still pays for consultation services, there are two choices.  
One:  the claim can be submitted to the primary with the consultation code, then the code must be changed to the appropriate OV or inpt E/M code before sending it to Medicare.  

Two: The appropriate OV or inpt E/M code can be submitted to the primary and then MSP will get the claim after the primary pays.  Our practices are going this route - determined the difference between the "regular" E/M and consultation reimbursement was not worth the extra work to change MSP claims.


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## jhume (Jan 8, 2010)

Hopefully this should help.  Gives all the details including the new modifier to use for inpatient services.

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf

Medicare is actually increasing payments for other E/M services (office visits, hospital care) to help offset some of the potential losses for the consultation dollars.  Not sure if it will make up all the difference, but may help some!

Jen


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