April 19, 2010

As of January 1, 2010, Medicare stopped accepting claims for consultation services (CPT® codes 99241– 99245 and 99251–99255). Instead, physicians are to report the appropriate evaluation and management (E&M) codes:

• - 99201-99205 (New Office/Outpatient Visit)
• - 99211-99215 (Established Office/Outpatient Visit)
• - 99221-99223 (Initial Hospital Care)(inpatient)
• - 99231-99233 (Subsequent Hospital Care)

CMS claimed that the change was budget neutral in that the total relative value units assigned to the consultation codes were redistributed among the E&M codes. Many anesthesiologists and other physicians are finding, however, that the lower payments for the E&M codes are putting a dent in their revenues.

Are you continuing to bill your commercial payers using the consultation codes? The new CMS policy (Change Request #6740; MLN Matters® Number MM 6740, revised February 24, 2010) only applies to Medicare. Some practices are being excessively conservative. Others are anticipating that private payers will follow Medicare’s lead, and some simply find it too complicated to select different CPT codes by payer.

Pain medicine practices in particular may be losing up to 19-36 percent on valid requests for opinion visits by reporting E&M services rather than the consultation codes to non-Medicare payers. See Table 1 below (these values only apply to office visits, not to inpatient services). Yet no major commercial payer appears to have adopted Medicare’s new policy, except for certain specific lines of business such as Medicare Advantage plans. Several payers explicitly denied any intention to eliminate the consult codes in one surgical specialty society poll.

Unless your private payers (as well as Medicaid, which varies from state to state) have signaled that they will no longer recognize the consultation codes, therefore, you do not need to give up this revenue.

In reporting the consultation codes to non-Medicare payers, it is still very important to document the services correctly. While CMS was preparing to eliminate the codes ostensibly to simplify billing for visits, the AMA-led CPT editorial board was rewriting some of the consultation-code instructions. (And late last year, AMA representatives met with CMS officials to seek a one-year delay in implementation on the grounds that the changes would be confusing! – to no avail.)

The most important editorial change to the section on “Consultations” in CPT® 2010 is in the first paragraph, which now provides:

A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

The question is whether an E&M service that involves both evaluation and treatment, i.e., a transfer of care, constitutes a consultation or a visit service. We concur with Marvel J. Hammer, RN, CPC of MJH Consulting in Denver that:

- IF the "receiving" physician agrees to accept transfer of care before the initial evaluation, then the receiving physician should report the E/M services with the appropriate office/outpatient (new or established) or inpatient (subsequent hospital care) visit code.

- IF, however, the decision to accept transfer of care cannot be made until after the initial evaluation, the appropriate office/outpatient or inpatient consultations code should be reported. (Personal communication, April 7, 2010.)

Consultations are also distinguished by a request from another physician, clinician, lawyer, insurance company etc. as opposed to a referral by the patient himself or by a family member. The request for the consult may be either written or oral, but it must be documented in the patient’s medical record by the requesting physician or by the “receiving” physician, i.e., the consultant.

A consultation also requires documentation of the consultant’s opinion and/or recommendations and of any services or procedures ordered or performed. The evaluation and any treatment must be documented in the medical record and communicated by written report to the requesting physician. Ms. Hammer, as well as ABC, recommend that pain physicians carefully document the identity of the requesting physician or “other appropriate source” and clearly indicate whether the consultant:

-is providing only his/her opinion on the patient's diagnosis and/or treatment –

-"Dr. Joe Brown asked for my opinion regarding this patient's chronic low back pain and potential diagnostic/treatment options. My detailed findings are as follows…."

OR

-provided the opinion and after performing the initial evaluation is accepting transfer of care for the patient or specific patient's condition –

-"I was asked by Dr. Joe Brown to evaluate this patient's chronic low back pain for potential treatment options. Following the initial evaluation, I have agreed to accept Dr. Brown's request for transfer of care for treatment of Ms. Green’s chronic low back pain. My detailed findings and treatment plan are as follows..."

Documenting the request for consultation and the report will also serve to establish medical necessity, should the payer ever deny a claim for lack of a specific diagnosis. More important, most true referrals between physicians will meet the updated CPT requirements for submitting consultation codes if documented properly. If your billing system permits you to submit either the consultation or the E&M service codes, depending on the payer (ABC encourages our clients to continue to document a consultation and to rely on us to crosswalk the consult code to the correct E/M code for Medicare), you should consider reporting the higher-paying consult codes to your commercial payers until and unless they tell you otherwise.

Update – Medicare 21.2% Payment Postponed Again

In another Congressional cliffhanger, late last week Congress blocked the 21.2% Medicare payment cut for another two months. Both the House of Representatives and the Senate approved H.R. 4851, the Continuing Extension Act of 2010, maintaining the payment freeze at 2009 levels until June 1, 2010. President Obama signed the bill late in the evening on Thursday, April 15, within hours after the Senate completed action.

Anesthesiologists and pain physicians will see no change in their payments from Medicare at least through May.

Another postponement is just another temporary fix. If the 21.2% reduction -- and future Medicare payment cuts – are to be blocked permanently, it will be because you continue to call your Senators and Congressmen to urge them to eliminate the Sustainable Growth Rate (SGR) formula. You will find all the up-to-date information you need for your citizen-lobbying at www.ASAhq.org, among other places.

We join you in breathing a sigh of relief over the adoption of the latest bill and in hoping that the payment cut brinkmanship will soon be replaced by a permanent legislative solution to the SGR problem.

With best wishes,

Tony Mira
President and CEO