Pediatric Coding Alert

Although CPT clarifies the transfer of care definition, the fix came too late for Medicare. Your private payers may follow suit.

The Office of Inspector General found a high error rate on appropriate use of consultation codes. Different opinions on when a transfer of care occurs versus a consultation caused $1.1 billion in incorrect payments.

"We couldn't even all agree on some scenarios," admitted William J. Mangold Jr., MD, JD, Medicare contractor medical director of Noridian Administrative Services (Arizona, Montana, Utah, Wyoming) in a session at the CPT and RBRVS 2010 Annual Symposium in Chicago.

Pediatricians who don't regularly code consults could gain from Medicare's position related to inconsistent and invalid codes for payment in 2010. CPT still considers the codes valid. CMS, however, will take the payments for 99241-99255 (Consultations) and redistribute them to office visits (99201-99215), hospital care (99221-99233), and nursing home (99304-99310) codes. This will create a 6 percent boost for primary care in outpatient and a 2 percent increase in inpatient E/M reimbursement from private payers that adopt the 2010 Medicare Physician Fee Schedule.

The differing rules, however, spell trouble. "We are going into Dante's Inferno for 2010," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions and senior coder and auditor for The Coding Network in Tinton Falls, N.J. "We will have to manage who does and who does not allow consultation codes." Each payer may decide at will to reject or to accept 99241-99255.

Example: A teacher requests a pediatrician's opinion on a child with behavior issues. The physician evaluates the child and reports his findings to the teacher. According to CPT, the pediatrician could report a consult code since the encounter involves a request for opinion (verbal or in writing), rendering of exam, and report of findings back to the teacher. If, however, the payer chooses to follow Medicare's lead and not recognize the consult codes, you would instead report an office visit code (99201-99215, Office or other outpatient service ...).

Since the history, examination, and medical decision making components do not match up for office visits and consults, the code level would change depending on the reporting method. This opens a can of worms. Auditors will have to figure out which service (office visit or consultation) the documentation supports.

Some payers that do not base their payments on Medicare's fee schedule may not follow Medicare's lead. At the AMA CPT and RBRVS 2010 Annual Symposium in Chicago, a medical director indicated that at least one payer will continue to use consult codes. "Blue Cross Blue Shield of Rhode Island will accept either method," said Peter A. Hollmann, MD, the AMA CPT editorial panel vice chair, in his "Evaluation and Management" presentation at the AMA symposium. "I'm not sure how helpful our decision will be for you considering how big a state Rhode Island is," Hollmann joked with attendees.

BCBS RI made this decision for two reasons:

1. "We wanted to allow physicians to report based on both CMS and CPT rules," Hollmann explains.

2. The contractor is not using the 2010 fee schedule because it can't implement the changes by Jan. 1, Hollmann reported. "Since we're not redistributing the relative value units" to pay office visits and hospital care services more in exchange for invalidating consult codes, "we won't change our consult policy."

Medicaid falls under CMS. Does that mean Medicaid will stop accepting consult codes as of Jan. 1?

The answer "depends on the Medicaid program in your state," responded Kenneth B. Simon, MD, MBA, CMS senior medical officer, in the Q&A portion of "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the symposium. "You'll have to wait for instructions in your state."

Here are two possible outcomes for one attendee's scenario. "As a neonatalogist, I'm asked for a newborn consult, but I'm not the primary care giver. Will I be able to report a consult?"

"In general, we instructed contractors in this kind of situation that the appropriate code is a hospital care code," Simon answered. You would use an initial care code (99221-99223) for the patient's initial care or a subsequent care code (99231-99233) for follow-up care. There's not currently a universal Medicaid plan, he pointed out.

For a Medicaid program that follows CPT, the neonatalogist could code a consultation code (99251-99255) for the encounter provided documentation supports the service's definition.