Urology Coding Alert

With non-payment for consults, you will need to relearn some old coding rules.

While most coders know by now that the rumors swirling about consultation coding and payment changes were true, confusion still runs rampant about how you'll deal with the changes.

CMS published the 2010 Physician Fee Schedule , which you can find at www.cms.hhs.gov/PhysicianFee Sched/PFSRVF. The fee schedule indicates that there are no relative value units (RVUs) assigned to the consultation codes, "so it looks like 100 percent certain Medicare won't recognize them," says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Now your job is to figure out how to report the consultation services your urologist provides so that he'll get paid for his services -- by both Medicare and private payers.

Since Medicare will no longer reimburse you for
in-office consultation codes (99241-99245, Office
consultation for a new or established patient ...) and inpatient consultation codes (99251-99255, Inpatient consultation for a new or established patient ...), you must learn new ways to capture your urologist's "consultation" services.

In the past, only the admitting physician reported initial hospital care codes (99221-CPT 99223 , Initial hospital care ...), and specialists who saw the patient subsequently and separately often billed inpatient consultation codes. With the no-pay policy on consult codes, CMS is poised to allow specialists to bill initial hospital care for their first visit with an inpatient.

How it works: If your urologist performs a consultation in the hospital, you should use an initial hospital code (99221-99223), according to Medicare's new consultation guidelines for 2010. "Stop thinking of these codes as admit codes," cautioned Peter A. Hollmann, MD, the AMA CPT editorial panel, vice chair, at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago.

Key: More than one physician can now use an initial hospital care code for the same patient. If two physicians from different specialties are both consulting on a patient, both physicians will use the initial hospital care code.

Each physician will be able to bill from the 99221-99223 code range only once, after which he or she will report subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) for follow up hospital visits.

Because multiple physicians may end up billing the initial hospital care codes during a patient's hospital stay, CMS will release a new modifier in 2010 that will signify which physician admitted a patient to the hospital, says Melissa Briggs, CPC, with Stormont-Vail HealthCare in Topeka, Kan.

"Because of an existing CPT coding rule and current Medicare payment policy regarding the admitting physician, we will create a modifier to identify the admitting physician of record for hospital inpatient and nursing facility admissions," confirms the CMS Physician Fee Schedule Final Rule. "For operational purposes, this modifier will distinguish the admitting physician of record who oversees the patient's care from other physicians who may be furnishing specialty care."

Fair warning: Surgery coders will have to educate primary care physicians who perform the majority of admissions to append modifier AI (Principal physician of record) to the initial hospital care CPT code to indicate their role as the admitting doctor. "The physician of record will use the initial code with a modifier," stressed Kenneth B. Simon, MD, MBA, CMS senior medical officer, in "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago. All other submitted claims for initial hospital care codes will presumably be for consultations.

Possible payment delays: If no one uses the modifier, the claim will be subject to medical review, Simon predicts. "Other claims will be held 'pending review,'" Simon said. So if the admitting physician does not correctly append modifier AI, your subsequent initial hospital care code could be held up.

Multiple physicians using the same hospital codes sounds like a recipe for denials, but nevertheless that's what Medicare is instructing physician inpatient consultants and care coordinators to do. Whether carriers will then deny these submissions as representing coordination of care or inpatient admission edits, policies and rules will be contractor specific, Charles E. Haley, MD, MS, FACP, Medicare medical director for Trailblazer Health Enterprises, LLC, told the audience during the E/M session at the 2010 CPT symposium. "If come January you're getting denials, work out the issues with your specific contractor."

Proper diagnosis coding is always important, but now that more than one physician can report initial hospital care, your ICD-9 codes better prove why two MDs are necessary for the same patient's hospital care.

Separate ICD-9 codes will help substantiate the medical necessity for providing consultative services, Simon explained. If an auditor reviews your hospital code (99221-99233) documentation, different diagnoses will show why more than one physician's E/M examination was necessary for the same patient.

If two physicians from different specialties are treating the same problem, there needs to be a clear medically necessary reason why the additional physician is there, said William J. Mangold, Jr., MD, JD, Noridian Administrative Services' (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director.

Teach your doc: Your urologist should include the reason he needed to see the patient. Separate diagnoses won't make a big difference in the initial claim processing phase, Simon said. They will, however, help support medical necessity.