General Surgery Coding Alert

Get used to skipping the CPT E/M consultationsection. Starting Jan. 1 you'll have to learn a new way to code services that you used to report with office and inpatient consultation codes -- and which payers expectyou to make that change.

Although CMS has halted payment for the in-office consultation codes (99241-99245, Office consultation for a new or established patient ...) and inpatient consultation codes (99251-99255, Inpatient consultation for a new or established patient ...) in 2010, the AMAchose not to delete the codes, keeping them in the CPT manual for another year.

Not a total $$ loss: CMS will raise payment for the other E/M codes to try and offset the consult payment 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. Also, CMS will increase surgical global period payments to reflect the higher value of the office visits furnished as part of the global package.

Watch other payers: Often private payers follow Medicare's lead, but not always -- and that's going to make your coding job harder in 2010. You'll have to find out who does and who does not allow you to report the still-valid CPT E/M consultation codes.

Experts expect some large carriers, including Blue Cross Blue Shield, Aetna, and Humana, to adopt the CMS policy for uniformity. For carriers and private payers that no longer recognize consult codes, let these examples help you decide what code to use instead.

There's no going back -- "CMS is saying the consult codes are going away," said William J. Mangold, Jr., MD, JD, Noridian Administrative Services' medical director at the CPT and RBRVS 2010 Annual Symposium in Chicago.

Which codes instead? When your general surgeon performs a consultation for a Medicare patient starting Jan. 1, you should choose the appropriate E/M code based on the applicable guidelines -- whether office/outpatient (99201-99215, Office or other outpatient visit...) or hospital inpatient (99221-99233 Initial/subsequent hospital care ...).

Example: An internist asks for your general surgeon's opinion regarding potential bariatric surgery for an obese patient. The surgeon saw the patient two years ago, and sees the patient in his office per the internist's request. There's no documentation in the internist's chart to confirm the request for opinion. How would you code the service under Medicare 2010 guidelines?

Answer: You would waive the referral requirement since non-consultation E/M coding rules apply, Mangold says. The surgeon treated the patient within the past three years, so you would apply new/established patient definitions. Therefore, you should assign an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) for this encounter.

At the higher levels, consults' transfer to hospital care codes will benefit your practice's bottom line. For 99244 and 99245, you would gain approximately 30 percent in pay if you also report the prolonged services, said Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair in his "Evaluation and Management" presentation at the AMA symposium.

"The lower level reimbursement impact will mostly be negative," Hollmann related. At the low consult levels, the hospital care codes do not match up well.

Don't miss mismatch: Code 99251 doesn't crosswalk to 99221, agreed Mangold. "They don't have the same criteria."

Example: On a patient's initial day in the hospital, a non-attending physician performs only a medically necessary problem-focused history and problem-focused examination. This would not support 99221's requirements of a detailed history and detailed exam, points out Joan Gilhooly, PCS, CPC, CHCC, vice president, Audit Services and Compliance for Health Management Resources in Salisbury, N.C.

Look to the hospital care code that appropriately describes the service, stresses Mangold. Medicare should clarify instructions on what to do when low level consult allowances don't support 99221 or 99231.

Consider using time to line up the services, suggests Hollmann. The following possible match-ups are "strictly from a CPT crosswalk -- not official from CMS." (Do not use them to code exactly but as a guide.)