Practice Management Alert

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.

The 2010 Medicare Physician Fee Schedule indicates the consultation codes are invalid for Medicare purposes (www.cms.hhs.gov/PhysicianFeeSched/PFSRVF). You can now be certain Medicare won't pay for the codes. Now your job is to figure out how to report the consultation services your physician provides so that he'll get paid for his services -- by both Medicare and private payers.

Since Medicare will no longer reimburse you for office (99241-99245, Office consultation for a new or established patient ...) and inpatient (99251-99255, Inpatient consultation for a new or established patient ...) consultation codes, you must learn new ways to capture your physician'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. If your physician performs a consultation in the hospital, you should use an initial hospital visit code (99221-99223) or subsequent hospital visit code (99231-99233), according to Medicare's new consultation guidelines for 2010.

"Stop thinking of 99221-99223 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. These codes are for initial hospital care that a physician provides. A consultant might see an inpatient who has been in the hospital for several days. If the physician is providing initial hospital care, he can use 99221-99223 even if he provides the care on a day subsequent to the admission day.

Catch: 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 for the first time, 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 on a patient's first day in the hospital, CMS will release a new modifier in 2010 that will signify which physician is the admitting physician, 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 append modifier AI on a 9922x claim, your initial hospital care code payment could be held up. Some carriers' reps, however, have specifically said that the AI modifier is informational only and the nonuse by the admitting doctor will not hold up claims. Be sure to check with your Medicare carrier on its modifier policy.

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 (99221-99223) 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 physician 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. Plus, different diagnoses will be especially important for follow-up care (99231-99233). As in the past, having unique and different diagnoses on their follow-up codes is still critical for your physicians in order to avoid concurrent care denials.