2009-12-23
Medicare Announces Major Policy Change Impacting Hematologists – Elimination of Consultation Codes
In the 2010 final Medicare Physician Fee Schedule the Centers for Medicare and Medicaid Services (CMS) announced that Medicare will no longer recognize consultation codes for Medicare Part B fee for service payment. CMS directs providers to report other evaluation management (E/M) codes in lieu of the consultation codes. In place of the consultation codes, CMS increased the work relative value units (RVUs) for new and established office visits, increased the work RVUs for initial hospital and initial nursing facility visits, and incorporated the increased use of these visits into the practice expense (PE) and malpractice calculations. CMS also increased the incremental work RVUs for the E/M codes that are built into the 10-day and 90-day global surgical codes. Despite these modifications, there is concern that this policy will have a negative impact on reimbursement for hematologists.
For some time now, CMS has been debating with the American Medical Association's CPT Editorial Panel regarding the appropriate reporting of consultation codes. CMS has argued that physicians do not use consultation codes properly. Specific areas of disagreement include the physician's responsibility for documentation of a referral and issues surrounding transfer of care. ASH and numerous other specialty societies strongly opposed this policy change when it was originally proposed earlier this year arguing that it devalued cognitive work performed by hematologists and other specialists. In addition, ASH and other medical societies also worked with Senator Arlen Specter (D-PA) to try and insert language to reinstate consult codes in the Senate health reform bill. This effort was not successful and, despite opposition, CMS has decided to stop making payments for consultation services starting January 1, 2010. The policy does not apply to Medicare Advantage or Medicaid. This article provides guidance to ASH members on this new policy.
All Consultation Codes Eliminated Except for Telehealth Services
As of January 1, 2010, Medicare will no longer recognize consultation codes. Providers should not report the following CPT codes on or after January 1, 2010:
- Office consultation for new or established patient (99241, 99242, 99243, 99244, 99245)
- Inpatient consultation for new or established patient (99251, 99252, 99253, 99254, 99255)
CMS has preserved telehealth consultations to provide the ability for practitioners to provide and bill for initial inpatient consultations delivered via telehealth where certain services or medical expertise might otherwise not be available to patients. CMS will allow providers to report the following Healthcare Common Procedure Coding System codes on or after January 1, 2010:
- Initial inpatient telehealth consultation (G0425, G0426, G0427)
Physicians who bill a consultation other than a telehealth consultation after January 1, 2010, will have the claim returned with a message indicating that Medicare uses another code for the service. The physician must bill another code for the service and may not bill the patient for a non-covered service.
Medicare Directs Providers to Report E/M Visit Codes in Lieu of Consultation Codes
CMS directs providers to report evaluation and management (E/M) visit codes in lieu of consultation codes. The agency has not provided specific crosswalks from consultation codes to existing E/M codes. Providers should code a patient evaluation and management visit with E/M codes that represents where the visit occurs and identify the complexity of the visit performed. Although consultation codes are being eliminated, CMS encourages providers to continue following conventional medical practice of documenting referral requests, referral acceptances, and communication of findings after the evaluation by the consultant to the referring physician.
Providers should report the following CPT codes for consultation services:
Hospital outpatient/office
In the office or other outpatient setting where an evaluation is performed, physicians should report new and established office/outpatient visit codes (CPT codes 99201-99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.
By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years. Unless
a different policy has been established by the payer, for this purpose,
hematology, hematology/oncology, and medical oncology are considered separate
specialties.
Hospital inpatient and nursing facility setting
For the hospital inpatient and nursing facility setting providers are directed to report initial hospital care visit codes (CPT codes 99221-99223) or nursing facility visit codes (CPT codes 99304-99306). The principal physician of record will append modifier "AI" Principal Physician of Record to the E/M code when billed. This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care. Subsequent inpatient consults will be reported as subsequent visit codes (CPT codes 99231-99233).
Selecting Appropriate Codes
CMS has not provided crosswalks from the eliminated consultation codes to existing visit codes. CMS is instructing physicians to select the code for the service based upon the content of the service. Medicare has noted that in order for physicians to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g. to bill a Level 5 new patient visit, the history must meet CPT's definition of a comprehensive history). It is also important to remember that the duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care.
Two sets of documentation guidelines have been developed to assist providers in the correct reporting of E/M services: the 1995 documentation and 1997 documentation guidelines. Carriers and A/B Medicare Administration Contractors (MACs) use both (whichever is more advantageous to the physician). Typically, for hematologists the 1997 E/M guidelines tend to be the most relevant. The guidelines are available online.
It is anticipated that the greatest confusion in this area will be with inpatient consultation services. While for outpatient/office consultation services providers will be going from five consultation codes to five E/M visit codes, in the inpatient setting providers are going from five consultation codes to three initial visit codes. Initially there may be some confusion regarding reporting Level 1 and 2 inpatient consultation codes (CPT codes 99251 and 99252), which do not meet the minimum criteria for a Level 1 initial inpatient visit code. In a recent conference call hosted by Medicare for providers, it was noted that one local carrier was advising physicians to report a subsequent visit code in place of a Level 1 or 2 consultation code while another carrier was advising providers to report an unlisted code. Currently, the national Medicare office is advising providers to contact their local Medicare carrier or MAC with any specific questions on coding in this area.
Prolonged Services
The elimination of consultation codes may raise questions regarding the appropriate use of prolonged visit codes. Prolonged visit codes are add-on codes billed with the primary evaluation and management (E/M) service. As an add-on code these codes cannot be reported independently, but must always be reported in addition to another E/M code. Prolonged visit codes are reported when treating patients whose symptoms are especially complex and concerning and the provider finds his or herself spending significantly more time with the patient. Prolonged visit codes 99354 and/or 99355 can be billed with the office or other outpatient setting E/M codes. Prolonged visit codes 99356 and/or 99357 are billed with the inpatient setting E/M codes.
CMS has established minimum threshold times to determine if the prolonged service can be reported. Physicians may count only the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. Documentation is not required to accompany the bill for prolonged services unless the physician has been selected for medical review. Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed.
Medicare Secondary Payment Scenario
In some instances, Medicare will be the secondary payer. Medicare will also no longer recognize the consultation codes for purposes of determining Medicare secondary payments (MSP). In MSP cases, physicians and non-physician providers must bill an appropriate E/M code for the services previously paid using the consultation codes. If the primary payer for the service continues to recognize consultation codes, physicians and non-physician providers billing for these services may either:
- Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or
- Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.
For billing purposes the first option is probably the easiest.
Further Information
CMS has released two articles to help educate providers about this new policy:
For specific coding questions not addressed by the educational materials listed above, ASH recommends that members and their staff contact their local Medicare carrier or MAC.
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