Practice Management Alert

If your practice relies on consultations for a good chunk of income, a new CMS proposal for 2010 could wreak havoc.

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

New way: Instead of reporting consult codes, you will report an initial hospital or an initial nursing home visit or a new or established patient office visit (E/M) code for these services. CMS has proposed plans to increase payments for these codes and other existing E/M codes. This change would "result in a net decrease in allowed charges of approximately $1 billion," noted CMS' Whitney May during a July 9 CMS Open Door Forum.

So how will the proposal 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 patient office visits (99211-99215, Office or other outpatient visit for the E/M 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 non-payment, 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 would lose between $16 to $45 for office consults that would now be coded as new patient visits, and you would lose $30 to $100 for office consults coded as established patient office visits, 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 particularly for specialists, who bill consults more often than primary care physicians. You'll have to wait until the new fee schedule comes out to see how next year's rates compare.

In the inpatient setting, the current alternative to using a consultation code is an initial hospital visit. "The difference in reimbursement (depending on the level of consultation) can be significant and can represent a significant piece of income for surgeons," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

Some billers 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 are non-consult E/M codes, the primary care physicians will get the benefit of the increased revenue without the loss of the consultation revenue. In contrast, specialists feel that the increase in 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."

Your revenue may be less, but foregoing reporting consults to Medicare may have some plusses.

1. Better compliance: "Compliant operations will be much simpler to implement, ensuring that services will be supported and there will not be an issue as to whether an E/M service is a request for an opinion or a transfer of care," Cobuzzi says.

2. Clear coding: 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."

More information: You can read the entire proposal in the Federal Register online at www.edocket.access.gpo.gov/2009/pdf/E9-15835.pdf.