How to Get Paid For Consulting When Medicare Eliminates Consultation Codes January 1, 2010
The CMS has released its final 2010 Physicians Fee Schedule. One of the most significant changes was the elimination of payment for consultation codes as of January 1, 2010.
This does not mean you can no longer do consultative work, it just means that you will have to bill these services differently than you do now. Here are the facts regarding this new ruling and the potential impact on your practice.
1. Consultation codes 99241-99245 (outpatient/office) and 99251-99255 (inpatient) have been eliminated effective January 1, 2010. Telehealth consultation G-codes (G0425-G0427) will not be eliminated.
2. Starting January 1, 2010, CPT codes for new (99201-99205) or established (99211-99215) patients should be used to replace consultations in the office/outpatient setting.
3. Starting January 1, 2010, CPT codes in the inpatient hospital setting (99221-99223) should be used to replace inpatient consultation codes (99251-99255), and for nursing facility consultations use codes (99304-99306).
4. To distinguish the difference between the admitting physician of record from the consultants for initial hospital inpatient and nursing facility admissions, CMS will develop a modifier. Currently, modifier "AI" is for principal physician of record, however Medicare has not finalized the modifier to be used for consultations.
5. Medicare states that its changes are budget neutral. RVUs for all E/M codes have been increased in an attempt to offset the fees lost from the elimination of consultation codes. The increase in E/M payments is approximately 6% for outpatient/office codes and 2% for inpatient codes above 2009 levels.
An important note regarding commercial or private insurance. No information has been released by other third party payers regarding payment for consultation codes as of yet. However, if a patient has Medicare as a secondary payer, a decision will need to be made by the physician as to how you will report the consultation. Any consultation claim filed with a commercial insurer such as Blue Cross or Aetna who is primary using the eliminated consultation codes when Medicare is secondary would result in a denial for the secondary claim by Medicare. In those instances where Medicare is secondary, you may want to consider using the new guidelines as stated above for reporting consultation codes.
One more note. If you have not updated your enrollment information with Medicare since November 2003, you must do so by April 5, 2010. Although enrolled in Medicare, many physicians who are eligible to refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare provider enrollment, chain and ownership system (PECOS) and also contains the physician's national provider identifier (NPI).
Questions and Answers
The 28000 procedure codes include dressings or casts applied at the time of surgery. The hospital bills for the DME (durable medical equipment), with one exception.
Though CMS has done away payment for consult codes, it will continue to honor split/shared visits — as long as they are billed using E/M codes and follow the payment rules already in place.
For CMS consultation codes 2010 updates, there are also one-stop coding websites you can turn to.
Consultation services are E&M services that are provided by physicians, based on a request by another physician or appropriate source.
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