Cardiology Coding Alert

ICD-9 may show why inpatient needs cardiologist and another MD.

The 2010 fee schedule -- as expected -- confirms that for Medicare patients, you'll be skipping the 99241- 99255 (Consultations) section of CPT. With the loss of consult fees on the horizon, apply hese tips to boost your chances of capturing every E/M correctly the first time.

Count Out Consults for Medicare Beneficiaries

CMS has declared that consult codes are taboo for its patients: "Beginning January 1, 2010, we will eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G codes) on a budget neutral basis by increasing the work RVUs [relative value units] for new and established office visits" and for initial hospital and initial nursing facility visits, the Medicare Physician Fee Schedule (MPFS) Final Rule notes.

This decision means that in 2010, you will report an appropriate non-consult E/M code for Medicare patients even if the visit meets CPT's consult requirements.

Example: "In 2009, if a cardiologist in the office setting performed a consult for an established patient with 786.50 [Chest pain; unspecified] that involved detailed history, detailed examination, and medical decision making of low complexity, you would report 99243 [Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...]," says Sandy Fuller, CPC, MCS-P, HIS supervisor and compliance officer for Cardiovascular Associates of East Texas.

But in 2010, for Medicare patients, you'll report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) if the consulting cardiologist or another physician of the same group practice and specialty hasn't seen the patient in the last 3 years, Fuller says. (Note that any face-to-face service, E/M or procedural, resets the three year window.) "If the patient was seen within the last 3 years you would bill 99214 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical  ecision making of moderate complexity ...] because Medicare will no longer accept consult codes," Fuller says. The key is to match the key components performed to the appropriate E/M code.

Shore Up Documentation, Dx for Inpatients

Inpatient visits will come with a separate challenge. In the past, only the admitting physician reported initial hospital care codes (99221-99223), and if your cardiologist saw the patient separately at the admitting physician's request, you'd often bill an inpatient consult.

But with the no-pay policy on consult codes, CMS is poised to allow specialists to bill initial hospital care for their first inpatient visit.

Modifier addition: Because multiple physicians may end up billing the initial hospital care codes during a patient's visit, CMS has released a new modifier for the admitting physician to use in 2010. According to Transmittal 1875, Change Request 6740, the admitting physician who oversees the patient's care must append modifier AI (Principal physician of record) to the initial visit code. Other physicians performing an initial hospital E/M on the patient should not append modifier AI; those physicians should report only the appropriate level E/M code without a modifier, according to information available at publication time. (Download the transmittal from www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf and the corresponding MLN Matters article from www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.)

Dx tip: Your ICD-9 codes also may help you support why two physicians are necessary on the same patient's hospital care. Separate ICD-9 codes will help substantiate the medical necessity for providing consultative services, explained Kenneth B. Simon, MD, MBA, CMS senior medical officer, in "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago. In other words, if an auditor reviews your hospital code (99221-99233) documentation, different diagnoses will show why more than one physician's E/M was necessary for the same patient.

The physicians also should be very clear in their documentation. If two physicians from different specialties are treating the same problem, there needs to be a clear medically necessary reason why the additional physician is there, said William J. Mangold Jr., MD, JD, Noridian Administrative Services' (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director. The doctor's documentation should include the reason he needed to see the patient.

Example: An oncologist may be treating an inpatient's breast cancer with trastuzumab. The patient develops congestive heart failure and requires the care of your cardiologist. The oncologist's claim would reference the cancer she's treating (174.x, Malignant neoplasm of female breast ...), and the cardiologist would list the congestive heart failure (such as 428.0, Congestive heart failure, unspecified).

Navigate Unchartered Consult Waters

The CPT 2010 manual does not delete the consult codes, so other payers may continue to accept them. Be sure to check so you meet all necessary requirements, such as having a written request on file.

Reality: Even if only Medicare eliminates the high consult code fees, specialty practices in particular will feel the pinch, says Susan Vogelberger, CPC, CPC-H, CPCI, CMBS, CCP-P, CEO of Healthcare Consulting and Coding Education.

CMS will raise payment for the other E/M codes to try to offset the consult loss. For instance, you'll see a 7 percent increase for 99214 (Office or other outpatient visit ...), with physician work RVUs rising to 1.50 from the 2009 rate of 1.42. But these adjustments are unlikely to make up for the loss of consult fees.

Experts suggest reviewing the services you already provide to be sure you're capturing every reportable code.

Keep in mind: Although Medicare has released the transmittal letter to all carriers instructing them about the policy change to no longer pay for consultations, Senator Arlen Specter (D-PA) introduced an amendment to the Patient Protection and Affordable Care Act (H.R. 3590) to delay this policy change by one year. This amendment was added on Dec. 14, 2009. If Congress does not pass this bill before the end of the year, the Medicare policy will go on as planned. Check Cardiology Coding Alert and http://codingnews.inhealthcare.com for more developments, but be prepared just in case.