Pulmonology Coding Alert

Question: I'm hearing that consultation codes may go away in 2010. How could this affect my practice?

Pennsylvania Subscriber

Answer: CMS has proposed ending coverage of consultation codes 99241-99255 to increase payments for primary care services, according to the new Medicare Physician Fee Schedule proposals, printed in the July 13 Federal Register. The AMA does, however, plan on maintaining the codes at least for CPT 2010.

What to do: For Medicare and private payers that adopt Medicare's consultation coverage change, you would use E/M codes (99201-99215 for office visits or 99221-99223 for hospital care), rather than consultation codes (99241-99245 for outpatient consults and 99251-99255 for inpatient consults).

The proposed rule suggests redistributing the savings that would result from invalidating consultation codes into payments for E/M services, such as office visits (99201- 99215, Office or Other Outpatient Services) and initial hospital care (99221-99223). CMS would still leave the values on 99241-99245 in the Medicare Physician Fee Schedule so that private payers can see the codes' RUC-(RBRVS Update Committee) and CMS-agreed upon relative value units (RVUs).

Impact: You'll have to keep track of insurers that accept 99241-99245 (Consultations). Private payers that base their fees on Medicare may drop payment for consult codes too, forcing you to use visit codes rather than traditionally higherpaying consult codes. For insurers that have their own fee schedules, you may still use the consult codes.

To determine the financial 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 E/Ms, 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, including pulmonologists.

Not set in stone: Whether or not the pay cuts will actually become final is anyone's guess. "Since far less draconian cuts have been reversed by Congress over the past seven years, and since the current plan in Congress and in the Obama administration is to finalize a healthcare reform package by November, I expect that this issue will be addressed before the draft regulation takes effect," says David C. Harlow, Esq., of The Harlow Group in Newton, Mass.

Potential good news: While consult codes are potentially on CMS's chopping block, you may be able to recoup a portion of those funds if your practice offers the "Welcome to Medicare Exam."

CMS proposes a payment boost for G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment), making payment rates for G0402 equivalent to CPT code 99204.

Therefore, the work RVUs for G0402 would increase to 2.30 as of Jan 1, 2010. The current work RVUs for G0402 are 1.34.