Urology Coding Alert

If you cringe every time you see the word "consultation" in your surgeon's documentation, CMS may have just the news you've been hoping for. A proposal for 2010 could eliminate the abundant confusion of what differentiates a consultation and a transfer of care. Find out what the proposal means for your coding and reimbursement.

In the July 13 Federal Register CMS announced a proposal to eliminate consultation codes starting on Jan. 1, 2010. The plan includes the elimination of 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.

This change would "result in a net decrease in allowed charges of approximately $1 billion," noted CMS's Whitney May during a July 9 CMS Open Door Forum. "I definitely think they'll stop paying for consultations, and I think the reason is because they can't control the cost of consultations," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

Good news: The consultation code deletion will make your coding life easier because it eliminates the constant arguments of what is and 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. When is a patient a transfer of care as opposed to a true consultation?" says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology in Pittsburgh.

"I think [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."

"It will make the coder's life easier because it eliminates the constant arguments of what is and isn't a consult," Ferragamo agrees. "Everybody had their opinion and any clarifications were never clear, if there even were clarifications."

New way: Instead of reporting consult codes, you will report a new or established patient office visit or an initial hospital or an initial nursing home visit (E/M) codes for these services. CMS has proposed plans to increase payments for these codes and other existing E/M codes. To make up for the elimination of the consultation codes, CMS will allow more than one initial hospital visit or initial nursing home visit, 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.

Private payers: This proposal, being from CMS, would apply only to your Medicare coding if it goes through. Private payers might also begin to follow suit, however, Cobuzzi says. "It may take a year for private payers to also stop paying on consultation codes, but the possibility exists," she adds.

According to the proposal, CMS plans to create an additional modifier for the admitting physician to append to the initial hospital visit codes. "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. 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," the Federal Register says.

The benefits: "This sounds like an excellent and logical idea," says Berman. "The initial visit has always been a point of confusion for many physicians. If they see a patient in consultation or they are managing an underlying condition, the code choices have been unclear."

If the physician's documentation was not done properly, you were unable to bill a consultation code; however, a subsequent visit code did not appropriately reflect the service, she adds.

Caveat: One caller during the July 9 Open Door Forum asked whether CPT will change its rules on initial hospital care. Currently, only the admitting physician can report codes 99221-99223, but if CMS halts consultation pay, other physicians may need to report codes from this series, the caller indicated. The CMS official noted that such changes have not yet been discussed with the CPT committee.

Other potential changes: "I believe the AMA will delete the consultation codes if this goes through," Shrader says, adding that she thinks that would be a good thing.

You'll have to wait until the AMA announces the CPT 2010 changes to find out whether you'll even have consultation codes to report any longer. Keep reading Urology Coding Alert for details as they emerge.