Pulmonology Coding Alert

The inevitable has happened -- Medicare no longer recognizes 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 guidelines.

Lowdown: Effective January 1, 2010, CMS has eliminated payment for "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 nursing facility visits, the Final Rule notes.

This means eliminating Medicare fee-for-service 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 is anticipated to 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 billed before 2010 versus all E/M codes. You will lose the RVU increment for all traditional Medicare patients for those consultations.

Silver lining: CMS has raised payment for the other E/M codes to 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 will still end up losing money.

Private payers: Because this ruling 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 maintains these codes, so you can submit them to private payers who still accept them for payment. 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 the payers' anticipated revenue preservation) 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 now because it eliminates arguments of what is or isn't a consult. You 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 should 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, initial or subsequent hospital care, or initial or subsequent nursing facility care (E/M) codes for these services. CMS has increased payments for some E/M codes. However the payments for subsequent hospital visit codes remain the same.

Example: A Medicare patient presents to your pulmonologist with recurrent episodes of acute bronchitis that her primary care physician (PCP) has treated in the past. The PCP sent the patient to your pulmonologist for his opinion. Therefore, the pulmonologist evaluates the patient, finds that the patient has bronchiectasis with recurrent bronchial infections, and recommends a medical regime to treat the patient. In 2010, you will no longer have to worry about any documentation issues and can report a new patient evaluation (99201-99205) code.

Impact: To determine the impact of this change, you'd have to compare the reimbursement from the new office visit fees versus last year's office consult fees, as well as the new hospital visit E/M charges versus the 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 2009'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 (6 to 8 percent) may not cover the loss of consult money. This could cause lower reimbursement for specialists in particular, who bill consults more often than primary care physicians.

Big loss: If a patient is referred to a pulmonologist, but that patient has been seen by another pulmonologist within the past 3 years (the 3 year rule), then the evaluation requested by the referring physician can only be billed using the outpatient visit codes (99211-99215), which may  pay up to 70 percent less than the former consult codes for the same level of service. Unfortunately you have no choice but to use these codes.

Small bonus: To make up for the elimination of the consultation codes, CMS now allows more than one initial hospital visit or initial nursing home visit, Cobuzzi says.

Note: CMS has added an AI modifier for the admitting physician to use with the initial hospital visit to indicate that the visit belongs to the admitting physician.

Reminder: If you employ a nonphysician practitioner (NPP) in your practice, NPPs are allowed to share/split initial services which they previously were not able to do when reporting consultations. NPPs still can provide new patient visits (99201-99205) and initial hospital care services (99221-99223) independently but cannot perform initial nursing facility care (99304-99306) according to state and federal regulations.