Otolaryngology Coding Alert

Find out how much CMS will raise payment for other E/M codes.

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 who don't follow Medicare's lead.

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, the Final Rule notes.

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. The best way to determine how badly your practice will be hurt is to run an E/M distribution report and determine the percent of consultations that you currently bill versus all E/M codes.

You will lose the RVU increment for all CMS patients for those consultations.

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. However, certain specialists still end up losing money.

Private payers: Because this proposal is from CMS, it would apply only to your Medicare Part B coding. It does not necessarily even apply to your Medicare HMO claims, unless that private  payer has indicated that they are following Medicare's new ruling. 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 or more (depending on how long the AMA keeps the codes in the CPT manual) for private payers to also stop paying on consultation codes, but the possibility exists," she adds.

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 presents to your otolaryngologist with recurrent sinusitis that her primary care physician (PCP) has medically treated for multiple courses. The PCP sent the patient to your otolaryngologist for his opinion. Therefore, the otolaryngologist evaluates the patient, does a nasal endoscopy, and recommends functional endoscopic sinus surgery for the patient. So long as you have documentation in order, you can report a consult code today. As of 2010, you will no longer have to worry about these documentation issues and can report an E/M service code.

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.

Note: CMS will be adding a modifier for the admitting physician to use with the initial hospital visit to indicate that the visit belongs to the admitting physician. Stay tuned to future issues of the Otolaryngology Coding Alert.