Wiki Elimination of Consult Codes

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sullivak

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I heard that Medicare finalized a rule on 11/6 that eliminates the office and hospital codes (99241-5 & 99251-5). These will now be coded using initial office and hospital admission codes (99201-5 & 99221-3). I work for a specialist whose practice is largely consultant based, and my head is spinning.:confused:

How should consults now be crosswalked for Medicare? For instance, if my doctor did a 99254 consult, what would be the corresponding code? I'm uncomfortable thinking in these terms as I'm used to thinking more in terms of guidelines, but are there official guidelines out there for this somewhere?

Thanks,
Kim, CPC
 
Medicare and consults

Hi,
I have not heard that Medicare is not paying for consultations. I just searched the medicare website and didn't see anything there either. Where are you getting this info??
 
Initial Hospital Visit

I believe Medicare has stated that it will accept the Initial Hospital Visit code from multiple providers to document each physician's FIRST visit with a patient during a specific hospitalization.

99254 requires a Comprehensive History, Comprehensive Exam, and Moderate MDM, so that would equate to 99222. I believe Medicare is also going to specify a modifier to be used to identify the "consulting" specialist vs the admitting physician, but I haven't seen any specifics on that yet.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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I'm starting to receive questions like...

Consultations could not be shared in the past. Since it appears that consultations will be reported with admission codes...can these, now, be shared since admissions can be shared... :confused: (doubtful)

For those consultations that don't meet detailed/comprehensive history, exam, etc....what do you report? :confused:
 
It certainly is opening a can of worms.

I am trying to think of it in terms of there are no consults anymore (well after 12-31-09) and just treating them like I would any admit(aside from the fact more than one provider will be able to use this code now). If they don't meet the requirements for 99221-99223 (which would be anything currently billed as 99251-99252) I use 99499. We are re-emphasizing the key components of the admit codes to all our providers. Many specialist rarely do them so this will be a pretty drastic change for them on the inpatient side.

On the bright side, you don't need a request, you don't need a report back, and you don't have to worry about using the right verbiage!

Laura, CPC, CEMC
 
The HCPCS modifier is going to be AI for the admitting physician of record to report. All others (consultants) will just report initial visit codes for their first visit in the hospital.

This is going to be an interesting ride for coding between all the different payors. Anyone heard of any other payors eliminating consults?
 
katmryn78 said:
It certainly is opening a can of worms.

I am trying to think of it in terms of there are no consults anymore (well after 12-31-09) and just treating them like I would any admit(aside from the fact more than one provider will be able to use this code now). If they don't meet the requirements for 99221-99223 (which would be anything currently billed as 99251-99252) I use 99499. We are re-emphasizing the key components of the admit codes to all our providers. Many specialist rarely do them so this will be a pretty drastic change for them on the inpatient side.

On the bright side, you don't need a request, you don't need a report back, and you don't have to worry about using the right verbiage!

Laura, CPC, CEMC
Click to expand...

I normally would too (99499) for those "out of norm" visits but this doesn't make sense to me for 99251/99252. 99499 is an unlisted code without a designated fee. Does this mean that any 99251/99252 is subject to review, everytime, to determine payment?? I hope not....
 
elimination of consult codes

rebeccawoodward said:
I'm starting to receive questions like...

Consultations could not be shared in the past. Since it appears that consultations will be reported with admission codes...can these, now, be shared since admissions can be shared... :confused: (doubtful)

For those consultations that don't meet detailed/comprehensive history, exam, etc....what do you report? :confused:
Click to expand...

Here's another question, how will we know who was actually asked to consult and who just entered the wrong code? My Docs all the time enter the wrong code and I have to go back and ask them if they admitted the patient on this date?, it might be two or three days into the hospital stay, they say "oh, no, that's wrong". Now, how will we know to check? Is there going to be a tracking mechanism for us to know who was actually a consultant? I think the modifier should go on the consult codes myself, but that's just my opinion!
 
Modifier AI

Where did you see the information about the AI modifier? I haven't been able to find anything on this. I am writing an article about the changes for our physicians and would like to reference this.
Thanks
 
Just to add to the chaos..

I see the comment about just Medicare. Keep in mind CMS is actually the Centers for Medicare and Medicaid Services. Where Medicare goes Medicaid tends to closely follow.

I checked with Michigan Medicaid today, they have not officially received anything but they expect to get something soon stating they will be following the directive to no longer pay for consults either.

Which makes sense to me, you would see not Medicaid fee schedules addressed in the Federal Register because they are run by the states, but it ultimately benefits the carriers to drop the consults why wouldn't they go with it.

Something to keep in mind and watch for,

Laura, CPC, CEMC
 
Double coverage should prove interesting as well...

Medicare Prim/Non-Medicare 2ndry versus Non-Medicare prim and Medicare 2ndry..... :eek:


"Some payers may choose to adopt this policy subsequent to this final rule. In cases where other payers do not adopt this policy, physicians and their billing personnel will need to take into consideration that Medicare will no longer recognize consultation codes submitted on bills, whether those bills are for primary or secondary payment.

In those cases where Medicare is the primary payer, physicians must submit claims with the appropriate visit code in order to receive payment from Medicare for these services. In these cases, physicians should consult with the secondary payers in order to determine how to bill those services in order to receive secondary payment.

In those cases where Medicare is the secondary payer, physicians and billing personnel will first need to determine whether the primary payer continues to recognize the consultation codes. If the primary payer does continue to recognize those codes, the physician will need to decide whether to bill the primary payer using visit codes, which will preserve the possibility of receiving a secondary Medicare payment, or to bill the primary payer with the consultation codes, which will result in a denial of payment for invalid codes."
 
Hi. I too heard about the elimination of 99241-99245. The new codes become 99201-99205. Hospital codes become 99221-99223. My question is this....I work for HEM/ONC and we see new patients in the office all the time in "consultation". What code (I used to use 99243-44-45) will I use in the office setting?

Hopefully there will be a decline in the the medicare cuts to oncology practices.
 
You will either use the new 99201-99205 or established 99212-99215 depending on the patients status with the group/specialty.

Consults and new patients require the same key components for the same level. So your 99243 would be a 99203 or if they are established with the practice a 99214. Your 99244 would be a 99204 or a 99215, and the 99245 would be a 99205 or 99215.

Laura, CPC, CEMC
 
The Federal Register showed a bit of a crosswalk, but discussed that a cross walk is not necessary if you are following the guidelines (which is true).

If you have a detailed history, a detailed exam, and a moderate decision-making, you can determine which code is most appropriate for your situation (99204 for a new patient, 99214 for an established patient, 99221 for an initial inpatient and a 99233 for a subsequent visit in the hospital.

Medicare as secondary payer does add a layer as they will not pay for consultations. However, getting information from your top payers as to how they are going to handle consultations should help.
 
Correction to the last post, Detailed history, Detailed exam, Moderate MDM is not a 99204 it is a 99203.

Laura, CPC, CEMC
 
I'm confused -- is this official now?

I know there's been a lot of speculation about the discontinuation of the consultation codes but is this now official? Since when? I haven't heard anything and can't find anything on the CMS website. Can anyone provide links to the announcement?
 
It's in the Federal Regs.....

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 admitting physician of record will be required to append the specific modifier to the initial hospital care or initial nursing facility care code which will identify him or her as the admitting physician of record who is overseeing the patient’s care. Subsequent care visits by all physicians and qualified NPPs will be reported as subsequent hospital care codes and subsequent nursing facility care codes.

http://www.federalregister.gov/OFRUp...9-26502_PI.pdf

This is not fun reading material but it provides everything you need to know...
 
I would also like to see documentation on the AI modifier, if anyone has it. Thanks~!
 
Late on Oct 30th, CMS shocked the medical practice industry with news that consultations would no longer be payable. this would eliminate payment for CPT 99241-99245 and 99251-99255. CMS has marked the consultation codes with a status "I" meaning not valid for medicare purposes. to offset the elimination of those payments, physicians are directed to the new or established patient office vist and subsequent visit codes. which received a two percent increase. at this time it is unknown which insurance payers will continue to pay for consultaions and which payers will mirror this new CMS policy. This information was provided by SVMIC. Kathy
 
Modifier AI

Search the CMS cite for the 2010 HCPCS levle II Modifiers - AI will be designated for the admitting physician. Consultants will use the appropriate initial hospital visit.
 
CMS pulication dated Dec 14, 2009 states:
"Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hopsital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221 - 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day."

And I was told my Medicare to use 99201-99205 for new patient "consultations" in the office in place of 99241-99245, as CMS no longer recognizes them either.

I am in the process of contacting BlueCross BlueShield, Aetna, ect. to see how they are going to respond to this. United Healthcare states they follow AMA guidelines, implying that they will pay on it as long as it is in the AMA CPT book. We'll see.
 
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