Medicare Compliance & Reimbursement

Center for Medicare and Medicaid Services (CMS) will no longer reimburse you for consultations effective Jan. 1, 2010, but your physicians will still collect for initial inpatient visits -- even if they didn't admit the patient -- thanks to a new modifier.

In the past, only the admitting physician reported initial hospital care codes (99221-99223), and specialists who saw the patient separately often billed inpatient consults.

New way: Now that Medicare won't recognize the consult codes, multiple physicians may report initial hospital care during a patient's visit. Therefore, CMS released new modifier AI (Principal physician of record), which the admitting physician will append to the code for his initial visit with the patient.

In black and white: "In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221-99223) or nursing facility care codes (99304-99306)," according to CMS Transmittal 1875, issued on Dec. 14, 2009.

"As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day," the transmittal reads. "Modifier AI ... shall be used by the admitting or attending physician who oversees the patient's care."

Note: As in the past, each physician will be able to bill from the 99221-99223 code range only once, after which they'll report subsequent hospital care codes (99231-99233). Although modifier AI will cure some confusion, coding these visits may still be difficult, particularly since some private insurers may opt to continue paying for consults.

In a hospital setting, "the physician often won't know which insurer the patient has, so they may not know whether to use the consultation codes or the initial visit codes," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and anesthesiology at the University of Pittsburgh Medical Center. "This willprobably rest on the shoulders of the coders until all payers' processes are identified."

(Editor's note: To read Transmittal 1875, visit: www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf.)