Ophthalmology and Optometry Coding Alert

Get used to a two-tiered system for 2010 -- consultation codes 99241-99255 for some payers, but not for Medicare.

Our experts help you identify and solve consultcoding pitfalls -- like how to garner pay when multiple physicians bill for initial care -- with the following four pointers:

Although Medicare Part B won't pay for consultation codes as of Jan. 1, not all payers have followed suit. Because CPT 2010 kept the consultation codes, some payers are opting to continue using them this year.

The no-consult policy applies only "to physicians billing the Medicare fee-for-service program -- it does not apply to Medicare Advantage or a non-Medicare insurer," said CMS's Whitney May during a CMS Open Door Forum on the change.

To ensure continued reimbursement, you should contact your major payers and determine their stance on billing consultation codes. You might also determine when they plan on making the change, if not immediately. Fiscal year or anticipated consult-code deletion from CPT 2011 might steer payers to select different dates.

Reality check: In a hospital setting, "physicians 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, CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and anesthesiology at the University of Pittsburgh Medical Center. "This will probably rest on the shoulders of the coders until all payers' processes are identified," she says.

Since you can't use 99241-99245, (Office consultation for a new or established patient ...) for Medicare, you'll need to turn to the following codes when your physician sees a patient in an office or outpatient setting: 99201-99205 -- Office or other outpatient visit for the evaluation and management of a new patient ...

• 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," says Betsy Nicoletti, MS, CPC, founder of Medical Practice Consulting in Springfield, Vt.

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.

Medicare will no longer pay for inpatient consultation codes either -- 99251-99255, (Inpatient consultation for new or established patient...). Instead, you'll have to choose from the following codes for hospital inpatients:

• 99221-99223 -- Initial hospital care ...

• 99231-99233 -- Subsequent hospital care ....

To use the inpatient codes, you first need to determine if you're dealing with initial or subsequent hospital care. Then you'll select one of three codes within that grouping based on the standard E/M guidelines for history/exam/decision making.

Problem: The consult codes provide five E/M levels, but the inpatient codes provide only three levels. That's left some practices seeking crosswalks that refer them from consult codes (which they're used to billing) directly to inpatient codes (which they're not used to billing). CMS issued a revised MLN Matters article (SE1010) on February 24, 2010, which clarifies their previous guidance on the consultation coding crosswalk.

CMS has advised providers to report the initial hospital care codes when documentation meets the requirements established for 99221"99223. However, if the history and/or examination do not meet the level established by 99221"99223, providers should report the subsequent hospital care codes (99231"99233) depending on the level of work and medical necessity.

Now that Medicare won't recognize the consult codes, multiple physicians may report initial hospital care during a patient's visit. That's different from what you're used to, when the admitting physician reported initial hospital care codes and specialists typically billed consults.

Dilemma: Who gets paid if two physicians bill initial hospital care? To solve the problem, 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.