Neurosurgery Coding Alert

The rumor about consultation codes becoming obsolete in 2010 became official when the CMS Final Rule was published on Oct. 30. Starting Jan. 1, 2010, CMS will no longer pay physicians for codes in the 99241-99245 (Office consultation for a new or established patient ...) or 99251-99255 (Inpatient consultation for a new or established patient ...) series.

"This will be budget neutral to CMS but not necessarily to your practice," says Betsy Nicoletti, MS, CPC, founder of Medical Practice Consulting in Springfield, Vt. Here's how she and other experts explain the bottom-line changes:

• CMS will increase the relative value units (RVUs) for new and established patient visits by 6 percent.

• CMS will increase the RVUs for initial and subsequent hospital visits by 2 percent.

• The increases are positive on the surface, but might not be in real life. "Obviously, this will result in an income increase for primary care specialties and a decrease for specialists who use consult codes," Nicoletti says. "The difference between a new patient visit and a consult was far greater than 6 percent."

"I think the determination of whether this is a potential win or loss situation would be very dependent on individual provider reporting patterns," says Heidi Stout, CPC, CCS-P, with The Coding Network LLC. "It could potentially hurt worse when an established patient is sent to a physician for consultation on a new condition. Instead of reporting a consult code, the physician will be forced to report an established patient visit, and that will be a big kick in the wallet."

Once the new rule goes into effect, code your claims based on the setting and patient status.

When your physician sees a patient in an office or outpatient setting, choose from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

"That's fairly straightforward, as long as you remember the definition of a new patient," Nicoletti says.

Definition: A new patient is one who has never received professional service from that physician (or another physician of the same specialty in the same group) during the past three years.

"Sometimes you have to look things up in your computer system to check if the patient is new," Nicoletti says. "There may be no chart because the physician (or the physician's same-specialty partner) saw the patient in the hospital or a different location. Someone could mistakenly select 'new' when the patient is actually 'established,' so be careful of that."

Code for an initial hospital service with the appropriate choice from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) -- what Nicoletti says many  physicians and other healthcare providers persist on calling "admissions."

Coming later: The admitting physician will add a modifier to his initial hospital service to distinguish himself from other physicians providing care to the patient. The modifier will be named later, so watch for details when it's released.

All physicians will report subsequent visit codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) for followup care.

Whether other payers will follow CMS's lead regarding consultation coding remains to be seen. "The consult codes are in the CPT 2010 book, with new commentary about transfer of care," Nicoletti says.

"We'll have to query our commercial payers individually to ask if they are changing their policies."

In the meantime, prepare to play by two sets of rules, depending on whether you're filing with Medicare or another payer.

Another consideration: How will the consult change affect your coding when Medicare's the secondary carrier? If the primary payer doesn't cover all the charge and it defaults to Medicare with consult codes, Medicare will deny the claim.

Answer: "The Final Rule basically said that if you expect there to be a Medicare balance due for a patient who has Medicare as the secondary carrier, you shouldn't use the consult codes when you file to the primary insurance," Nicoletti says.