2009-12-23
Medicare
Changes Affecting Physician Payment Beginning January 1, 2010
There are several Medicare changes affecting physician payment
beginning January 1, 2010. ASH wants to make sure you are aware of the
following: elimination of consultation codes; freeze in Medicare physician fees
through February 28, 2010; holding of claims processing through January 15,
2010; and a revised January 2010 ASP pricing file and crosswalk. Please read the items below for additional details.
CMS
Eliminates Use of Consultation Codes: As of January 1, 2010, Providers Directed
to Report Other Evaluation Management (E/M) Visit Codes
In the 2010 final Medicare Physician Fee Schedule (MPFS)
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.
ASH and other specialty societies strongly
opposed this policy change when it was originally proposed earlier this year. ASH
argued that it devalued cognitive work performed by hematologists and other
specialists. In addition, ASH and other medical societies worked with Senator
Arlen Specter (D-PA) to try and insert language in the Senate health reform
bill to reinstate consult codes. Unfortunately,
this effort was not successful, and CMS has decided to stop making payments for
consultation services starting January 1, 2010.
The policy does not apply to Medicare Advantage or Medicaid.
All
Consultation Codes Eliminated Except for Telehealth Services
As of January 1, 2010, Medicare will no longer recognize
consultation codes, with the exception of telehealth services.
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)
Providers can continue to code for:
- 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 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. CMS 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.
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.
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 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 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.
Prolonged Services
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 is 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.
Further
Information
ASH has published an article further detailing how the new policy will affect hematologists.
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.
Medicare
Physician Fee Freeze Through February 28, 2010
Congress has
included a measure in the Department of Defense spending bill that will prevent
the 21 percent scheduled Medicare physician fee cut from taking effect January
1, 2010, and freeze physician payments at their 2009 level through February 28,
2010. Although Congress and the
Administration continue to pledge their commitment to replacing the current
Medicare physician payment formula, it is not clear what will happen after
February 28. To avert the 21 percent cut
from going into effect, new legislation will have to be passed. ASH will continue to urge Congress to repeal
the flawed formula used to establish physician payments and will keep you
apprised of all developments.
CMS Will Hold Medicare Claims January 1 to January 15, 2010
CMS has instructed its contractors to hold
claims containing services paid under the MPFS for the first 10 business days of January (January 1 through January 15)
for 2010 dates of service. This should have minimal impact on provider cash
flow because, under current law, clean electronic claims are not paid any
sooner than 14 calendar days (29 days for paper claims) after the date of
receipt. Meanwhile, all claims for services delivered on or before December
31, 2009, will be processed and paid under normal procedures.
CMS Posts January 2010 ASP
Pricing
CMS has posted the revised January 2010 ASP pricing file and
crosswalk. All are available for download.
Health Reform Update: Senate Plans to Pass Health Reform Bill
Christmas Eve
As this issue of the Practice Update went to press, the
Senate was preparing to vote on its
version of health reform legislation, HR 3590, on Christmas Eve, and the bill is expected to
pass by a party-line vote with all 60 members of the Democratic caucus
supporting it and all Republicans opposing.
Key to passage were negotiations resulting in the Manager’s Amendment, which provides several revisions that have
convinced the last Democratic hold-outs to vote for the bill. The Manager’s Amendment includes several
provisions of interest to hematologists, including an increase in bonus
payments to primary care physicians and general surgeons in medically
underserved areas while not cutting payments to non-primary care physicians. This is an issue that ASH worked hard on
to prevent further cuts and protect access to specialists. Additional details of the House and Senate
bills are available on the ASH Web site.
Assuming
that the Senate bill is passed on Christmas Eve, the House-Senate conference
will begin in January. It will require
both Houses to reach compromise on the differences between the two bills.