General Surgery Coding Alert

Your surgeon will likely feel the pain more than his internal med colleagues.

As you read in the previous article, CMS's proposed 2010 fee schedule seeks to eliminate payment for consultation codes. So how will that affect your bottom line?

Here's what the experts think you should know.

Part of the CMS proposal seeks to increase the work relative value units (RVUs) for new (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) and established office visits (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) and increase the work RVUs for initial hospital (99221- 99223, Initial hospital care, per day, for the evaluation and management of a patient ...) and initial nursing facility visits (99304-99306, Initial nursing facility care, per day, for the evaluation and management of a patient ...).

Keep in mind: CMS is also projecting a record 21.5 percent rate cut in 2010. To determine the impact of this change and the consultation code deletions, 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 vs. 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 to $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, who bill consults more often than primary care physicians. In the inpatient setting, the current alternative to using a consultation code is a subsequent hospital visit. "The difference in reimbursement (depending on the level of consultation) can be significant and can represent a significant piece of income for a surgeon," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. The new process that requires the use of initial  hospital codes means that history and physical exam must always reach at least a detailed level, Bucknam explains.

There will be no way to bill a problem focused or expanded problem focused inpatient consultation. If you see the patient for the first time and your examination is not at least detailed, you will be stuck with the more poorly reimbursed subsequent hospital visit codes, coders lament.

The up side: The impact in the outpatient setting will be much less significant most of the time, Bucknam says. Only patients with multiple consultations (who will end up being coded as established patients) will have much of an impact on the bottom line.

Some coders and physicians feel that this change will help revenue for primary care practices, but will hurt the revenue for specialists, 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. They contend that because the bulk of what primary care physicians' code is E/M, the primary care physicians will get the benefit of the increased revenue without the loss of the consultation revenue. In contrast, specialists feel they that the increasein E/M RVUs may not make up for what they will lose in consultation revenue.

"From the specialty physician's prospective, consultations are performed a lot. Their opinion is vital to the care and well-being of the patients. The requesting physicians value the opinions, the knowledge, and the abilities to help the patients," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology in Pittsburgh. "Not having these coding options for those specialty providers could be viewed as a devaluing of their work, additional knowledge, and abilities regarding the patient outcomes. Increasing the RVU value of the other E/M services doesn't change this."

Silver lining: "Maybe the revenue is going to be a little less, but it's truly going to be better from a compliance point of view," Cobuzzi says. "So many of the consultations that specialists are billing out may not be able to be supported in an audit and could result in a major compliance problem, refund issues, and possibly a legal problem. This is to head that off and eliminate some confusion. So, in the short term, it looks like it could hurt you financially, but in the long term, it's a better thing from an operations and compliance point of view."

More information: You can read the entire proposal online at http://edocket.access.gpo.gov/2009/pdf/E9-15835.pdf. You can comment on the proposal until August 31 at www.regulations.gov. Follow the instructions under the "More Search Options" tab.

"There is a lot of talk about this proposal -- mixed reviews throughout the community of coders, consultants, and physicians," Berman says. "Again, it is a major change that should not be introduced without proper comment from many sources."