Neurosurgery Coding Alert

In the July 13 Federal Register, CMS announced a proposal to eliminate consultation codes starting on Jan. 1, 2010. Rumors have abounded since then, 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.

Private payers might also begin to follow suit, however, 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. "It may take a year for private payers to also stop paying on consultation codes, but the possibility exists," she adds.

Coding Medicare claims should be easier when the change takes effect because it eliminates arguments of what is or 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 Rs 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?'"

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.

Impact: To determine the impact of this change, you'd have to compare the reimbursement from the new fee schedule office visit fees versus the current office consult fees, as well as the new hospital visit E/M charges versus 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 and $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 in particular, who bill consults more often than primary care physicians.

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, Cobuzzi says.

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," the Federal Register states.

"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 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 your physician didn't properly document what was done, you were unable to bill a consultation code; however, a subsequent visit code did not appropriately reflect the service your surgeon rendered, Berman adds.

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

Other potential changes: "I believe the AMA will delete the consultation codes if this goes through," Shrader says, adding that she thinks that would be a good thing.