Orthopedic Coding Alert

The rumor about consultation codes becoming obsolete for Medicare 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 ...) code 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 Nicoletti and other experts explain the bottom line changes:

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

• CMS will increase the work 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."

Determining whether the change is a potential win or loss situation would be very dependent on individual provider reporting patterns, other experts say. For example, the change could potentially hurt more 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 Medicare claims based on the setting and the beneficiary's 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.

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 of record will add a modifier to his initial hospital service to distinguish himself from other physicians providing care to the patient. "The new modifier might be AI (Principle physician of record)," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. "This is a new modifier listed in the 2010 HCPCS file from Medicare, although there is nothing published as of yet if this will be the actual modifier. It's another case of wait and see."

All physicians will report subsequent visit codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) for follow-up inpatient 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 a patient has Medicare as secondary insurance and you bill a consultation, Medicare will not pay you because it will no longer recognize the codes, Hammer says.

"The issue becomes somewhat problematic if the primary insurance leaves a patient balance (such as coinsurance or a deductible) and the service needs to be reported to Medicare," Hammer adds.

Answer: Here's a partial answer, straight from the Final Rule: "In those cases where Medicare is the secondary payer, physicians and billing personnel will first need to determine whether the primary payer continues to recognize the consultation codes. If the primary payer does continue to recognize those codes, the physician will need to decide whether to bill the primary payer using visit codes, which will preserve the possibility of receiving a secondary Medicare payment, or to bill the primarypayer with the consultation codes, which will result in a denial of payment for invalid codes."