Radiology Coding Alert

Be sure you catch which physician should use new modifier AI.

You finally may have gotten comfortable with the idea that radiologists may code consultations, but in 2010, CMS has declared that consult codes are taboo for its patients.

What to do: CMS’s decision means that in 2010, you should report an appropriate non-consult E/M code for Medicare patients when the visit meets CPT’s consult requirements. Apply these tips to boost your chances of capturing every E/M correctly the first time.

Don’t Expect an Easy Crosswalk

The rule: “Beginning January 1, 2010, we will eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G codes) on a budget neutral basis by increasing the work RVUs for new and established office visits” and for initial hospital and initial nursing facility visits, the Medicare Physician Fee Schedule (MPFS) Final Rule notes.

Example: In 2009, if a physician in the office setting performed a consult for an established patient that involved detailed history, detailed examination, and medical decision making of low complexity, you would report 99243 (Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity …), says Sandy Fuller, CPC, MCS-P, HIS supervisor and compliance officer for Cardiovascular Associates of East Texas.

But in 2010, for Medicare patients receiving that same service, you’ll report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity …) if the consulting physician or another physician of the same group practice and specialty hasn’t seen the patient in the last three years, Fuller says. (Note that any face-to-face service resets the three year window.)

“If the patient was seen within the last three years you would bill 99214 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …] because Medicare will no longer accept consult codes,” Fuller says. The key is to match the key components performed to the appropriate E/M code.

Bolster Your Documentation, Dx for Inpatients

Inpatient visits will come with a separate challenge. In the past, only the admitting physician reported initial hospital care codes (99221-99223). If your radiologist saw the patient separately at the admitting physician’s request, such as for resting leg pain, you may have billed an inpatient consult. But with the no-pay policy on consult codes, CMS now allows specialists to bill initial hospital care for their first inpatient visit.

Modifier addition: Because multiple physicians may report the initial hospital care codes during a patient’s visit, CMS has released a new modifier for the admitting physician to use in 2010. According to Transmittal 1875,  hange Request 6740, the admitting physician who oversees the patient’s care must append modifier AI (Principal physician of record) to the initial visit code.

Note that the modifier consists of the letter “A” and the letter “I”: “AI.”

Other physicians performing an initial hospital E/M on the patient should not append modifier AI; those physicians should report only the appropriate level E/M code without a modifier, according to information available at publication time. (Download the transmittal from www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf and the corresponding MLN Matters article from www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.)

Dx tip: Your ICD-9 codes also may help you support why two physicians are necessary on the same patient’s hospital care. Separate ICD-9 codes will help substantiate the medical necessity for providing consultative services, explained 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.

In other words, if an auditor reviews your hospital code (99221-99233) documentation, different diagnoses will show why more than one physician’s E/M was necessary for the same patient.

The physicians also should be very clear in their documentation. 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. The doctor’s documentation should include the reason he needed to see the patient.

Continue to Watch for Consult Updates

The CPT 2010 manual does not delete the consult codes, so other payers may continue to accept them. Be sure to check so you meet all necessary requirements, such as having a written request on file.

Keep in mind: Although Medicare has released the transmittal letter to all carriers instructing them about the policy change to no longer pay for consultations, Senator Arlen Specter (D-PA) introduced an amendment to the Patient Protection and Affordable Care Act (H.R. 3590) to delay this policy change by one year. This amendment was added on Dec. 14, 2009. But as of publication time, the Medicare no-consult policy has gone into effect as planned. Check Radiology Coding Alert and http://codingnews.inhealthcare.com for more developments.