Neurology & Pain Management Coding Alert

Your 99241-99255 revenue -- and your compliance risk -- could be headed for a nosedive.

CMS wants to take the consult money pool and give it to office visits, among other services, meaning your consult revenue will go down. Rumors have abounded since the suggestion, so here's the latest information on what the proposal could mean for your coding and your practice's reimbursement.

The plan includes eliminating CMS reimbursement for all inpatient (99251-99255, Inpatient consultation for a new or established patient ...) and outpatient (99241-99245, Office consultation for a new or established patient ...) consultation 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."

Private payers: Because this proposal is from CMS, it would apply only to your Medicare coding if it goes through. CPT 2010 and the fee schedule will still include the codes, so you can submit them to private payers.

Coding Medicare claims should be easier if the change takes effect. 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."

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 determine the impact of this change, you'd have to compare the reimbursement from the new fee schedule office visit fees vs. the current office consult fees, as well as the new hospital visit E/M charges vs. the current hospital consult fees, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Using this year's figures, you'd lose between $16 to $45 for office consults that would now be coded as new patient visits, and you'd lose $30 to $100 for established office consults coded as established patient follow-up visits, Buechner says. A rough calculation shows that the additional E/M payments (proposed at 6 to 8 percent) may not cover the loss of consult money. This could cause pay cuts for specialists.

Small bonus: 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, president of CRN Healthcare Solutions in Tinton Falls, N.J.