# New medicare consult coding changes



## heatherwinters (Jan 13, 2010)

I listened to NGS's second free telephone conference yesterday on coding changes for consultations and I am still confused.  

This is my understanding thus far: 

If the consult occurs in the ED and you do not admit the patient, you use the ED codes to report your services based on History, Exam and MDM

If the consult occurs in the in-patient setting, you report it using the initial care codes unless you do not have a high enough level if history and exam to bill a 99221 in which case, you would have to revert to a subsequent care code based on the level of documentation you do have.

For observation patients, you would use the 99201 to 99215 codes to report your consult based on whether or not you have seen the patient as an outpatient in the past 3 years.  The exception would be those admitted and discharged on the same day, in this case your consultation would be reported using the 99234 to 99236 codes.

The AI modifier is not reserved strictly for the "admitting" MD.  It is only to be reported by the MD who expects to be managing the patients care during their entire hospital stay.

The confusion I have is in how they now interpret the initial care codes.  I asked the question, If Dr. X sees a patient over the weekend in the hospital and Dr. Y (the patient's primary care MD from a different practice) comes in on Monday and assumes care of the patient, what code should be reported.  In this case, the response I got was that Dr. X would bill the initial care codes, and Dr. Y would bill the initial care codes with the AI modifier because he will be the MD responsible for the patient's care during the in-patient stay.  This confuses me because in the past, Dr. Y was not providing a "consultation" in this case, he was simply taking over the patient's care and would only have been able to code a subsequent care code.  According to the information I received yesterday ALL MD's who see a patient for the first time in-patient can use the initial care codes for their first meeting with the patient during that admission.  Now I have consulted another coding specialist regarding this scenerio and he disagrees feeling that, 


> If a doctor was covering for my doc and did the initial visit I have to treat that patient as we are in the same group.  Unless a true transfer from one hospital to the other occured, I'd suggest my doc use a subsequent care code and not another 99221-99223.  I'd also suggest that the initial doc covering for me treat that patient as my patient and bill with the AI.  I know that is different but I don't feel that portion of the rules has changed. "


Does anyone else have any thoughts on this scenarioreviously, if an MD from a different practice saw a patient in the in-patient setting but did not really provide a "consult" he was simply helping cover for the weekend, he would have only billed a subsequent care code, can that MD now use the 99221-99223 codes to report his first encounter as long as the H, E and MDM requirements are met? Because that is explicitly the understanding I got yesterday.  I even pointed out to the presenters that this change would work in some MD's favor as now they would be eligable for higher reimbursement, and they agreed with me.  Who else has heard similar information?


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## cheermom68 (Jan 13, 2010)

*consults*

I would have to agree with the specialist that you quoted.  It would seem to me that the same rules would apply, same practice, same specialty=same doctor.  Just my two cents.


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## heatherwinters (Jan 13, 2010)

*Consult*

Same practice, yes I would say subsequent, but in this instance it would be a different practice, that is why I am confused.


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## LLovett (Jan 13, 2010)

The way I understand it is every unique provider should get to charge the intial codes the first time they come in as long as someone in their specialty/practice has not already done so. There is no rule that I am aware of that says if the same specialty from a different group has seen the patient already you can't use the initial codes. If there is someone please post it and the link to it.

Since they took away the consult requirements everytime an indivual provider comes in they should all be looked at the same way. 

This works out great for my primary care providers. Previously say a surgeon admits the patient, then their blood pressure goes out of whack and they ask the primary to come in and manage it. This was a subsequent care day since they were already admitted and not a consult, now it is an initial.

Laura, CPC, CPMA, CEMC


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## heatherwinters (Jan 13, 2010)

*Subsequent Care - 1st time seeing - now initial care*

This is my understanding as well.  I have talked to another coding specialist who disagrees and he had indicated that he feels this is not the case.  That is why I wanted to make sure that my understanding is correct.  I have an internal med doctor who will also benefit from this in this scenario because previously there were many times when he to has been called upon to manage a portion of the patient's care and now his first encounter should be able to be billed as a consult.  Does anyone else have a different understanding on this?


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## FTessaBartels (Jan 13, 2010)

*Medicare INTENDS to better pay PCP*

One of the intentions of the change regarding consultations is to free up money previously spent on incorrectly reported consultation codes to allow for an increase in pay for primary care physicians. One way to do this is to allow each unique provider to code the initial hospital visit for the first visit to the patient during that hospitalization. 

The PCPs will definitely benefit by this change. Good for them!

F Tessa Bartels, CPC, CEMC


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## heatherwinters (Jan 14, 2010)

*Coding Consult*

Has anyone found any articles that specifically outline this aspect of the change as a benefit so I can lay to rest any opposition that this is indeed the case?


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## RebeccaWoodward* (Jan 14, 2010)

Per CR 6740...

"CMS increased the work relative value units (RVUs) for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our practice expense PE and malpractice calculations. CMS also increased the incremental work RVUs for the evaluation and management (E/M) codes that are built into the 10-day and 90-day global surgical codes."


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## FTessaBartels (Jan 14, 2010)

*WPS teleconference*

I listened to the WPS teleconference today on the CMS change to consultation codes.

Re Doctor X covering for Doctor Y WHEN they are from TWO different practices.  Doctor X admits patient on Saturday; Doctor Y first sees patient in the hospital on Monday.

If Doctor X is billing under his/her own tax ID, then, when Doctor Y first sees the patient Doctor Y codes the initial hospital visit with AI modifier (because Doctor Y will be the doctor of record for this patient for this hospital stay). Doctor X would use the initial hospital visit code as well, but with*out* the AI modifier. 

If Doctor X is billing as "reciprocal" ... i.e. Doctor X's services are billed as if he were Doctor Y under Doctor Y's tax ID, then Doctor X bills the initial visit on Saturday with AI modifier, and Doctor Y will be billing the subsequent hospital visit when s/he actually sees the patient. 

I hope CMS realizes what a complete MESS they have made of everything!

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Lisa Bledsoe (Jan 14, 2010)

Now I always thought that if Dr A and Dr B were taking call for each other; of the same specialty but different practices; they could not both code an initial visit or consult - but rather subsequent care.  What am I missing?  If one is covering call for the other, as is quite common, how can we justify all these 99231-99233's floating around?


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## Jamesmmm (Jan 15, 2010)

there's logic related to this in CODING EDGE Oct, 2009 here's the link:

http://djk9qtinkh46n.cloudfront.net...ca2c/c341385b-b661-4b53-8c92-38a666b0e966.pdf 

"E/M levels are all about giving the doctor credit for his/her cognitive work in evaluating the patient...if a doctor is encountering a problem for the first time, even if the patient is established within the practice, more cognitive work is required by the physician…”

 by Marvel Hammer, RN, CPC,CCS-P, PCS,ACS-PM, CHCO

Therefore, if the doctor does a work-up on a patient new to him/her, it seems that a new encounter code can be billed?

There's also a quote favoring similar logic by a former HCFA-CMS executive

Of course, I'm new to this…

JAMES


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## FTessaBartels (Jan 15, 2010)

*New problem NOT new patient*



Jamesmmm said:


> there's logic related to this in CODING EDGE Oct, 2009 here's the link:
> 
> http://djk9qtinkh46n.cloudfront.net...ca2c/c341385b-b661-4b53-8c92-38a666b0e966.pdf
> 
> ...



I understand your confusion, James.  But what this is saying is that if the problem is new to this physician, then he gets problem points for a NEW problem in determining MDM.  The *patient* is still *established*; but the *problem *is *new*. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Wicherki (Feb 3, 2010)

*Dr Training*

I agree that only true specialty consults should be using consult or initial care codes.  I am currently doing professional services billing where the provider submits the code. Every APRN, PA, and Dr that sees a patient was using the consult codes.  They only changed to the inital admit because they have to.  Even with that we are now sending back submitted charges because they are up coding when submitting the Medicare initial care codes.  What level of exam was it then?  I can see why Medicare put their foot down and said "no more".


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## becka95 (Feb 9, 2010)

So I just got off the phone with Medicare because I am now getting denials for consults codes that we billed as initials. The response I got was the patient was seen by my doctor as a consult. He is a Trauma/General surgeon. Patient was also seen on consult by a Cardio Surgeon but because they are both surgeons, only one can bill the consult as a initial visit (99221-99223) Since the other surgeon billed as the initial visit, ours got denied and I was directed to bill as a subsequent. 

I pulled out the webinar to see if this was addressed and it was not. I also looked through all my notes that I have on this mess and there is nothing that I can find to show that only one initial visit can be billed by the same type of specialist during a stay. I understand if they were both General Surgeons but they are not. 

Anyone else running into this? My director recommend that I call Medicare back tomorrow to see if I get the same answer. So Frustrating!


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## LLovett (Feb 9, 2010)

*Not yet....not holding my breath either*

Is it because they are in the same group? Who is your medicare carrier?

This is concerning me, I have CVT surgeons and many times there are other surgeons also seeing the patients during the same stay. We are not in the same group though so I have no idea what it happening with their billing. So far no rejections on our end though.

I am going to write this question down to ask in an upcoming WPS audioconference. 

Laura, CPC, CPMA, CEMC


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## becka95 (Feb 11, 2010)

Two different dr's and specialty and group. 

Ortho for the Radial Fracture, Neuro for the skull fracture with Subdural Hematoma. 

So Frustrating! I am attending the Medicare Webinar tomorrow and I plan to ask this question. I also pulled the MLN matters from 1/1/10 and there is nothing in there about this. Our carrier is Highmark.


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