# consultation changes for 2010



## 00017917

hopefully someone can clarify that CMS has made a final ruling on 2010 Consultation changes for specialists? i am unable to locate any ruling on the CMS site and only bits and pieces on the AMA site and HealthLeaders media.

are specialists only able to bill for new pt or follow up pt codes for 2010 and could someone send me CMS site for final ruling? i called medicare and they do not have a clue about the decision. please help and if they can only bill new pt. codes and follow ups what happens if they present with a new problem??

Carol


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## hawkinsj

*CMS ruling on consults*

Ya just gotta love CMS, they drop a bombshell but do nothing to follow up with helpful information.  I too am trying to find out.  An inside tip from HighMark, CMS, told me that yes CMS indeed ruled on it but has not made a formal announcement but that it should be forthcoming.  

Also, what happened to RAC?  Seems it just fell of the face of the earth???  Of course I don't have three weeks to devote to searching the CMS website either!

Janet


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## mmoroney

*2010 Consultations*

The information you are looking for regarding consultation codes for 2010 is located in the final rule published in the 11/25/2009 federal register.  CMS is no longer reimbursing for the consultation codes, most likely other payors will follow suite.  The consultation codes are still valid CPT codes.  Hope this helps!

http://www.access.gpo.gov/su_docs/fedreg/a091125c.html


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## tammster

Highmark is planning a webinar in January regarding the Consultations.  It isn't up on their website yet, though.  But, at least it's coming.  I think they showed it as tentatively slated for January 13th.  

It was information that was included on one of the slides from todays webinar I attended, but not on the slides that you get to print-out.


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## apmc

*When are they planning on filling us in?*


So, Medicare decides to eliminate the Consult codes, ok- I guess we have to deal with this.
So my questions are:
1) What am I allowed to bill for doing the report that still needs to be done for the referring doc because even though we cannot BILL for a CONSULT, it will still BE a CONSULT?  99080?  99499?
2) Since consults are typically more extensive are we going to be able to get paid for prolonged services codes (99354, 99356) or are they going to hold up the entire claim until we submit notes on every claim like what's been going on with our geriatrics physician?
3) Finally, and most importantly, I've read more than enough on the ruling, how about giving us some final details on HOW we are going to be billing for Inpatient Consultations as Subsequent visits?  Just stating that "we will create a modifier" does not help me.  Telling me WHAT the modifier is and WHICH doc will use it and letting me know sooner than 2 weeks before this new ruling goes into effect......THAT would be helpful.

And while I'm on a roll - how about giving us the final fee schedule details instead of just the RVU's which are a royal PITA to figure out.  This way we can at least get a general idea of how much of a revenue loss this will be.

Well now, I feel a little better now that I vented.  If anybody has any insight, please share- it would be much appreciated.
Thanks!

p.s.- oh and I can't wait for the other payors to "follow suit".  Especially the ones who increase their required copays to specialists even though they do not pay any more that a GP.  Now the insurance co's can make even MORE profits!


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## dentfam

*Consults and the ABN*

So...
does that mean that we can have the patients sign an ABN like we do for physicals and charge the patient?


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## mitchellde

dentfam said:


> So...
> does that mean that we can have the patients sign an ABN like we do for physicals and charge the patient?



No, the service of a consultation is still a valid and recognized service.  Read careful... it says that CMS considers the codes for consultation as invalid codes.  You have clear instructions on how to bill tese services you cannot bill the patient with an ABN.


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## kanaya

Has anyone heard yet the modifier admitting/attending physicians are to use to distinguish them from the specialists in the inpatient setting?


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## wpsmith4967

*Consultations*

I've heard that the modifier will be AI (i) not a 1 (one).  How confusing is that going to be.  I wonder if specialists will have to rely on the admitting physicians to put this modifier one before they'll pay?


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## lurrea

*Consults for 2010*

You can find the final ruling in the Federal Register, November 2009. These sort of things are always posted in there.

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3539

and

http://edocket.access.gpo.gov/2009/E9-28211.htm

Good Luck!
Lisa


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## kimwest

*ER visits*

Does anyone know how to bill an ER visit for a Medicare patient in 2010, if the visit previously met the criteria to be billed as a consult how should it now be billed?


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## RebeccaWoodward*

The proposed crosswalk is 992*01*-992*15*.  However, there is still an open issue with 99281-99285 since the current rule allows...

*Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting*

If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met. If the criteria for a consultation *are not met *and the patient is discharged from the Emergency Department or admitted to the hospital by another physician, the physician contacted by the Emergency Department physician should bill an emergency department visit. If the consulted physician admits the patient to the hospital and the criteria for a consultation are not met, he/she should bill an initial hospital care code.

Since 99284 carries 2.56 RVU's and 99204 (assuming they are new) carries 2.30 RVU's, I could see physicians preferring the ER CPT codes.


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## rinny

mm3290 said:


> The information you are looking for regarding consultation codes for 2010 is located in the final rule published in the 11/25/2009 federal register.  CMS is no longer reimbursing for the consultation codes, most likely other payors will follow suite.  The consultation codes are still valid CPT codes.  Hope this helps!
> 
> http://www.access.gpo.gov/su_docs/fedreg/a091125c.html



You can find it on page 31-39. Hope that helps.


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## christy0708

*Consultations*

Hello,

Are you all sure consultations are going away after this year.  I just spoke with a representative for Medicare Trailblazer (Oklahoma, Texas, New Mexico, and Colorado).  He said that nothing had been finalized at this time and that consults were still going to be valid next year as of right now.  He said Medicare was primarily focused on fine tuning the fee schedule at this time and may or may not finalize their plans for consultations.  I have explored the links provided by everybody, but I found his comments very interesting

Thanks
Christy


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## tammster

Several of the Medicare contractors have told me that they just have not received their finalized instructions from CMS and are still awaiting that before passing on any information regarding the consultations.


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## phoyt

*Consults*

Medicare in Arkansas has release the fee schedules.  No consults are included on the fee schedule.


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## Walker22

Same in Georgia...


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## tammster

Highmark Medicare is having a webinar on 12/22/09 on the topic "in-hospital visits".  It might be interesting to attend and ask questions.    

to register:
https://highmark.webex.com/mw0305l/...tail&confViewID=565084463&siteurl=highmark&&&


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## bethann2779

asma_wagih said:


> You can find the final ruling in the Federal Register, November 2009. These sort of things are always posted in there.
> 
> http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3539
> 
> and
> 
> http://edocket.access.gpo.gov/2009/E9-28211.htm
> 
> Good Luck!
> Lisa



thanks! LOL


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## coachlang3

How are split/shared visits going to be looked at now for Inpatient?

We had a webinar in our office last Friday (but it took place earlier so we couldn't ask questions) that shows on one of the slides "Split/shared visits look to be allowed now".  This is for MD's and mid-levels.

Any ideas?

Thanks,
Fred


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## ReginaR

Medicare in NY released it's fee schedule.  No consultation codes.  

I am not happy with this as I work for an oncologist and she is always doing consultations.

Hopefully CMS will reverse it's decision as physician's cannot take any more cuts.  Pretty soon all we will be getting paid will be the patient's copay....


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## Walker22

reginar said:


> pretty soon all we will be getting paid will be the patient's copay....



lol...


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## ReginaR

*Consultation codes definitely omitted*

Hello all.  I am in NY and just returned from a Medicare seminar.  Unfortunately it is not good.  It was just confirmed that Monday night, the finalization was passed on the discontinuance of consultation codes.  It is unfortunately the truth.

The other thing is that the modifer is AI (as in ARTIFICAL INTELLIGENCE).

Just thought I would post for all to see that it is true....no consultation codes in 2010.......


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## RebeccaWoodward*

I believe this was posted on another link but below is the finalized CR...

http://www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf


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## tammster

Senator Arlen Specter has proposed (this week) an amendment postponing the elimination of consultation codes for one more year.  He'd have to get congress to pass the amendment before the end of the year, in order to get the extension.

http://www.news-medical.net/news/20...ection-and-Affordable-Care-Act-applauded.aspx


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## RebeccaWoodward*

tammster said:


> Senator Arlen Specter has proposed (this week) an amendment postponing the elimination of consultation codes for one more year.  He'd have to get congress to pass the amendment before the end of the year, in order to get the extension.
> 
> http://www.news-medical.net/news/20...ection-and-Affordable-Care-Act-applauded.aspx




I just can't see that happening....


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## tammster

I would think that if it was such a concern for him, he should have started earlier on his crusade.


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## pamasbury

*Consult changes*

Here is what I've found regarding billing: 

By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims.  Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached.

For services that were outpatient consults, provided in the office and outpatient department, use new or established patient visit codes.  (99241--99245 will be 99201--99215).  Review the definition of a new patient from the CMS manual:

Interpret the phrase “new patient” to mean a patient who has not received any 
professional services, i.e., E/M service or other face-to-face service (e.g., surgical 
procedure) from the physician or physician group practice (same physician specialty) 
within the previous 3 years. 

Some patients, who would have been office/outpatient consuts will now be established patients.  The consult codes were not defined as new or established.  Specialty designation is critical, as well as the three year time period.  Remember that location is not a factor.  Whether the physician or the physician's same specialty partner saw the patient in the hospital or office doesn't matter in the specialty designation.

Admitting physicians must now use modifier AI (capital I, not number 1) on their claim forms to indicate they are the admitting physician when they bill for the admission, 99221-99223.  All other physicians who see a patient for the first time will also bill using the initial hospital services codes (what we call the admission codes 99221-99223).  CMS has instructed carriers to pay for multiple "initial" hospital services for the same patient, even if they are on the same day.  Remember, however, that physicians of one specialty in a group can only bill one of those/admission. The AI modifier needs to be attached only to the initial hospital services codes, not to the subsequent visits or discharge services.  However, CMS has instructed carriers to ignore the modifier if it appears on other line items during the admission.

How does a physician bill who is called to the ED to see a patient, who is not admitted?  Use the ED department codes (99281--99285).  Previously, these were billed with outpatient consult codes, if the criteria for a consult were met.  This means, physicians of multiple specialties will all bill ED codes on the same patient, on the same date of service, perhaps for the same diagnosis.  We can only hope that the Medicare Administrative Contractors will not deny these claims.

If a patient is in observation status, the admitting physician uses the OBS codes without a modifier, 99218--99220 or 99234--99236.  Other physicians who are called to see the patient should use office and outpatient codes, 99201--99215, keeping in mind the definition of a new patient visit.

Hospitalists will be able to bill the initial hospital services codes for their post-op evaluations, by my reading of this change request, for medically necessary, non-surgical management of medical problems.  Previously, they were limited to a subsequent hospital visit.  I will change the Codapedia article on that topic as well.


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## Cyndi113

Hi there, 

could you post the transmittal number, please? I need to take this to my providers and they want the "official" CMS word.

THANKS!


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## RebeccaWoodward*

http://www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf

also.......

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


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## lorrainevaldes

mitchellde said:


> No, the service of a consultation is still a valid and recognized service.  Read careful... it says that CMS considers the codes for consultation as invalid codes.  You have clear instructions on how to bill tese services you cannot bill the patient with an ABN.



so what codes are we to use for in patient consults by specialist 99222-99223?  I do understand office codes new and f/u.  any comments?


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## traci schuller

*E/M University*

E/M University has a presentation on Medicare and consult codes...it's free. I recommend everyone check it out.

My question is....are the codes themselves going away?


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## tammster

On 12/23/09 NGS is doing two teleconferences on the topic of 2010 Consultation Changes

Check out the event calendar:  
http://www.ngsmedicare.com/ADC/Even...idn=877&view=EventDetails&information_id=1153
and 
http://www.ngsmedicare.com/ADC/Even...idn=878&view=EventDetails&information_id=1155

There is no registration required.


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## VRock

The transmittal released as linked below gives the most information yet. (Make sure you have the revised version.) It includes the modifier AI and what you are supposed to bill in each scenario.  When you read it, you really need to think of it as primary or admitting physician normal billing rules vs. secondary or consulting physician's new rules for billing consults.  You are receiving an increase on your normal EM codes on the fee schedule. This is for all physicians including PCPs and specialists.

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

Valerie Rock CPC ACS-EM


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## tammster

For those of you that still have questions about the 2010 consultation changes - I urge you to attend the NGS teleconference this afternoon (2pm to 4 pm EST).  Call 866-837-0303  ID: 48308077.  I attended the one this morning - and it was great!!!  And...they left lots of time at the end of their presentation to take questions.


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## RebeccaWoodward*

I have to admit...I'm beginning to believe this is going to be an easy transition for us.  I had one lingering question that many were hesitate to answer.  I contacted our Medicare medical director and received an immediate response.  I'm starting to see the light at the end of the tunnel...


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## tammster

I feel a lot more comfortable about what is expected from us especially since the call.  

There were many people concerned about the ramifications of the Admitting Physician forgetting the AI modifier (as was I) and wondering if that was going to affect the specialists that get called (dare I say 'consulted'?) in.  They assured us that at this time, they have not been instructed of any edits (for the modifier) to implement for the new year.


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## hermoines

*Good One Susan,   My Sentiments exactly!!!!*




apmc said:


> So, Medicare decides to eliminate the Consult codes, ok- I guess we have to deal with this.
> So my questions are:
> 1) What am I allowed to bill for doing the report that still needs to be done for the referring doc because even though we cannot BILL for a CONSULT, it will still BE a CONSULT?  99080?  99499?
> 2) Since consults are typically more extensive are we going to be able to get paid for prolonged services codes (99354, 99356) or are they going to hold up the entire claim until we submit notes on every claim like what's been going on with our geriatrics physician?
> 3) Finally, and most importantly, I've read more than enough on the ruling, how about giving us some final details on HOW we are going to be billing for Inpatient Consultations as Subsequent visits?  Just stating that "we will create a modifier" does not help me.  Telling me WHAT the modifier is and WHICH doc will use it and letting me know sooner than 2 weeks before this new ruling goes into effect......THAT would be helpful.
> 
> And while I'm on a roll - how about giving us the final fee schedule details instead of just the RVU's which are a royal PITA to figure out.  This way we can at least get a general idea of how much of a revenue loss this will be.
> 
> Well now, I feel a little better now that I vented.  If anybody has any insight, please share- it would be much appreciated.
> Thanks!
> 
> p.s.- oh and I can't wait for the other payors to "follow suit".  Especially the ones who increase their required copays to specialists even though they do not pay any more that a GP.  Now the insurance co's can make even MORE profits!


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