# 2010 proposed rule and consults



## LLovett (Aug 14, 2009)

I am the first one to admit I will be happy to see consults go away. I will not be happy to lose the money though.

Has anyones accounting department done the analysis of the impact it will have on the bottom line? I was putting together a newsletter for my facility and I started doing the comparisons. I got about half sick.

Outpatient is not too bad, at least there are 5 code levels to crosswalk to. It is still a hit though. Currently medicare approves $ 124.79 for a 99243 that would be equal to a 99203 if they are a new patient, which they approve $ 91.97 for, or a 99214 if they are established which they approve $ 92.33. Not good but not near as bad as inpatient.

Inpatient consults would crosswalk to subsequent care codes. This means that 99255, 99254, and 99253 would all be coded as 99233. Currenlty we get $ 201.97 for 99255, $ 165.55 for 99254, and $ 114.69 for 99253. 99233 is $ 95.58. 

I haven't spoken to our accounting department, yet, and I really don't look forward to hearing what they have to say. I just wanted to see if anyone else had looked at the impact this will have. Are your offices submitting comments to CMS on this? 

I have several specialists and consults are the bulk of their E/M services. Ouch is all I can say at the moment.

Laura, CPC, CEMC


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## Lisa Bledsoe (Aug 14, 2009)

Laura - your post has definately sparked my interest.  I thought I read somewhere that the differnce in reimbursement for a consult vs new patient or subsequent hospital was going to be adjusted on the Medicare fee schedule "accordingly".  I'll be darned if I can find where I read that, though.  I would love to hear other's comments and concerns on this issue.  I too will be jumping for joy once consult codes are gone with the exception of the impact that will have on the bottom line...


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## LLovett (Aug 14, 2009)

They state that "Resulting savings would be redistributed to increase payments for the existing E/M services". 

To me the kicker is they don't say how much and they don't actually state they are going to increase above the current rate. My fear is instead of increasing, they just won't cut those rates any further and leave them as they are.

I guess we will see....

Laura, CPC, CEMC


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## Lisa Bledsoe (Aug 14, 2009)

Good point.


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## mmorningstarcpc (Aug 14, 2009)

If you go to the end of the proposed rule, its lists the "propsed" RVUs for physicians for 2010 by CPT.  The conversion factor is proposed at $28.3208 per RVU, so mulitply; or look at the RUVs for this year (2009) and compare.  I am traveling and can't do this right now, but hope this info helps.


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## LLovett (Aug 18, 2009)

*Info from the Federal Register*

I actually sat here and read thru this, fun. This is an interesting twist. They are saying for inpatient consults they are going to create a modifier for the primary admitting doctor to use with their admit and let providers who would normally use consult codes use the admit codes as well. This would mean more work for providers that routinely do 99251 & 99252, and of course it is still a pay cut for the other 3 inpatient consult codes down to admits.

"If we adopt this
proposal, then we will make
corresponding changes to our
regulations at § 410.78 and § 414.65. In
addition, we will add the definition of
these codes to the CMS Internet-Only
Medicare Benefit Policy Manual, Pub.
100–02, Chapter 15, Section 270 and the
Medicare Claims Processing Manual,
Pub. 100–04, Chapter 12, Section 190.
Outside the context of telehealth
services, physicians will bill an initial
hospital care or initial nursing facility
care code for their first visit during a
patient's admission to the hospital or
nursing facility in lieu of the
consultation codes these physicians
may have previously reported. The
initial visit in a skilled nursing facility
and nursing facility must be furnished
by a physician except as otherwise
permitted as specified in § 483.40(c)(4).
In the nursing facility setting, an NPP
who is enrolled in the Medicare
program, and who is not employed by
the facility, may perform the initial visit
when the State law permits this. (See
this exception in the Internet-Only
Medicare Claims Processing Manual,
Pub. 100–04, chapter 12, § 30.6.13A).
An NPP, who is enrolled in the
Medicare program is permitted to report
the initial hospital care visit or new
patient office visit, as appropriate,
under current Medicare policy. 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.
We believe the rationale for a
differential payment for a consultation
service is no longer supported because
documentation requirements are now
similar across all E/M services. To be
consistent with OPPS policy, as noted
above, we will pay only new and
established office or other clinic visits
under the PFS."

Laura, CPC, CEMC


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## kumeena (Aug 18, 2009)

can anybody share the crosswalk for hospital clinic visits. I will appreciate it.

thank you


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## dballard2004 (Aug 19, 2009)

Can someone post a link to the rule, please?  Thanks.


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## RebeccaWoodward* (Aug 19, 2009)

Is this what you're looking for Dawson?

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


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## dballard2004 (Aug 19, 2009)

It is.  Thanks so much!


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## kte01a (Aug 26, 2009)

That's great info about the modifier to be used by the attending physician.  I was wondering how that would be differentiated...multiple admit codes by different physicians, possibly on differing dates...how confusing would that be to track?


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## Colliemom (Oct 26, 2009)

I think this is coming a little late in the year - aren't the CPT's already at the printers?  

I don't mind the consult codes, I hope they do not approve this.  I work for a specialty group and we have a high percentage of our E&M reimbursement dependent on consultations.


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## LLovett (Oct 26, 2009)

This does not affect CPT at this time. It would just be CMS(that we know of) that would no longer pay for consults but they would still be in the book.

What has been fairly consistent over the years though is that CMS tends to lead the pack, where they go the rest usually follow. So the odds are, if CMS stops paying everyone else will too.

The final rule should be out a week from today.

Laura, CPC, CEMC


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## FTessaBartels (Oct 26, 2009)

*Wouldn't it be easier ...*

Wouldn't it be easier if CMS just PAID the consult codes at the equivalent new patient or initial patient visit?

But nobody asked me ...

F Tessa Bartels, CPC, CEMC


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## LLovett (Oct 26, 2009)

lol, easy, that will be the day! When did CMS ever want anything to be easy?

I am certainly concerned about this everybody getting an intial charge on the inpaitient side. As of right now, if your provider is called in to take over a piece of the care they just get a subsequent care day. Are they going to qualify for an initial care day too? Is everyone going to use the admit codes the first time they see a patient since there won't be any consult guidelines to follow if they do away with them. The documentation is going to be a nightmare, they are so used to documenting less unless they do the admit...not looking forward to that part at all. But I will be glad to see the consults go.

Laura, CPC, CEMC


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## Colliemom (Oct 29, 2009)

based on an article I read, there would be a new modifier created to use with the 99221 -99223 codes for inpatient hospital codes, to differentiate between the admitting physician and the consulting physician.

And wouldn't this also entail re-wording the code descriptions for 99201 - 99205 and 99221 - 99223?

I am really hoping that this won't happen this year.  I don't know about anyone else's physicians, but my physicians will need a little longer to prepare and adjust to these changes.  (Also, not looking forward to their response when they learn about the lost revenue this change will cause.)


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