Ob-Gyn Coding Alert

The inevitable has happened -- Medicare will no longer recognize consultation codes in 2010, but don't tear out those pages altogether. You can still submit these codes to non-Medicare payers ... for now.

Lowdown: "Beginning January 1, 2010, we will eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G codes) on a budget neutral basis by increasing the work RVUs for new and  established office visits" and for initial hospital and initial nursing facility visits, according to Medicare's Final Rule.

This means 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.

The elimination of consult codes will hurt specialty practices in particular, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting and Coding Education.

Silver lining: CMS will raise payment for the other E/M codes to try and offset the consult loss. For instance, you'll see a 7 percent increase for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), with physician work RVUs rising to 1.50 from the 2009 rate of 1.42. Additionally, Medicare will also raise the work RVUs for 10- and 90-day global surgical codes to account for E/M code increases. Certain specialists, however, still end up losing money.

Private payers: Because this proposal is from CMS,it would apply only to your Medicare coding. 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.

Don't lose heart though. If you have any benefit from this news, it's that 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.

Example: A Medicare patient who sees her internal medicine physician, Dr. Cress, for her high blood pressure has a complaint of postmenopausal bleeding and an abnormal Pap smear. Dr. Cress requests a consultation from Dr. Water, a gynecologist, to evaluate this problem. Dr. Water determines that the patient may have stage 1 endometrial cancer and possible treatment will include surgery.

2009 way: Currently, as long as your documentation meets all the requirements for a consultation, Dr. Water can bill 99244 for his consultative service which consisted of a comprehensive history and exam and moderate complexity of medical decision making.

2010 way: You would code this same service in 2010 as 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) if the patient was new to the practice or Dr. Water had not seen her within the past 3 years, or 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) if the patient was established to Dr. Water's practice within the past 3 years.

Now that you understand the consultation to regular E/M code change, 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, advises 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 inpatient consultation codes, CMS will allow more than one initial hospital visit or initial nursing home visit, Cobuzzi says.