Gastroenterology Coding Alert

If you cringe every time you see the word "consultation" in your gastroenterologist's documentation, CMS may have just the news you've been hoping for. Find out what the proposal would mean for your coding and for your practice's reimbursement.

In the July 13 Federal Register CMS announced a proposal to eliminate consultation codes starting on Jan. 1, 2010. The plan includes eliminating all inpatient (99251-99255, Inpatient consultation for a new or established patient ...) and outpatient (99241-99245, Office consultation for a new or established patient ...) consult codes.

This change would "result in a net decrease in allowed charges of approximately $1 billion, which we are proposing to bundle back into the initial hospital care visits and initial nursing facility care visits," stated CMS's Whitney May during a July 9 CMS Open Door Forum.

"Payment for these visits would also increase, depending on how we account for the practice expense associated with a consult."

Good news: The consultation code deletion will make your coding life easier because it eliminates the constant arguments of what is and isn't a consult. You will no longer have to determine which consultation coding advice to follow or scour your physician's documentation for the three R's of consultations: request, rendering of services, and return of the patient to the requesting physician.

"There has been much confusion about consultations in general," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology in Pittsburgh. Coders often ask, "When is a patient a transfer of care as opposed to a true consultation?" "I think [the change] will put an end to the confusion for consult versus transfer of care," adds Collette Shrader, CCP-P, in the compliance/education department of Wenatchee Valley Medical Center in Washington. "I think it will make the coders' and auditors' lives easier."

New way: Instead of reporting consultation codes, you would report new or established patient office visit or hospital care (E/M) codes for these services, and CMS would increase payments for the existing E/M codes.

To make up for the elimination of the consultation codes, CMS will allow more than one initial hospital visit or initial nursing home visit, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions.

Watch out for: "Although this is a budget-neutral proposal, the net effect will shift some dollars from specialists to internists," warns Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. "CMS has been looking for a method to do this for some time."

Private payers: This proposal, being from CMS, would apply only to your Medicare coding if it goes through. Private payers might also begin to follow suit, however, Cobuzzi says. "It may take a year for private payers to also stop paying on consultation codes, but the possibility exists," she adds.

According to the proposal, CMS plans to create an additional modifier for the admitting physician to append to the initial hospital visit codes. "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 Federal Register says.

The benefits: "This sounds like an excellent and logical idea," says Berman. "The initial visit has always been a point of confusion for many physicians. If they are seeing a patient consultation or they are managing an underlying condition, the code choices have been unclear." If the physician's documentation was not done properly you were unable to bill a consultation code; however, a subsequent visit code did not appropriately reflect the service your surgeon rendered, she adds.

Plus, if your physician was seeing a patient for an underlying condition, you couldn't properly identify the first visit either, Berman laments. "Now, with this modifier (if it comes to fruition), there will be truer reporting of the services being done for the patient," she says. "All will know who the admitter was and who saw the patient thereafter."

Caveat: One caller during the July 9 Open Door Forum asked whether CPT will change its rules on initial hospital care. Currently, only the admitting physician can report 99221-99223, but if CMS halts consult pay, other physicians may need to report codes from this series, the caller indicated. The CMS official noted that such changes have not yet been discussed with the CPT committee.