CMS Deletes Consultation Codes in 2010

CMS has deleted the consultation codes in 2010.  This has created a lot of questions for the healthcare providers, specifically the specialists. The following Q&A will aid you with some of the common questions:

Will these new changes decrease your revenue?

If compared at the same CPT level e.g. 99243 versus 99203, the effect will be negative. However, the new office visits (99201-99205) pay at a higher level in 2010 compared with the same CPTs in 2009.  This means that if you are a specialist and your consult utilization is higher than your visit utilization, your practice will generate less money for these services than you did last year. 

Will non-Medicare payers follow Medicare’s changes?

It would depend on the payors’ discretion to pay or deny your claim.  It does not help the situation that the consultation codes have not been deleted from the 2010 CPT manual.  But if a payor pays for a consultation code and Medicare happens to be the secondary on the same claim, Medicare will not reimburse its secondary portion.

Is there good news with the changes?

One good news is that providers do not have to worry about meeting the burdensome documentation requirements for a consult:

  1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source;
  2. A request for a consultation from an appropriate source and the need for the consultation must be documented in the patient’s medical record; and
  3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

What codes will be utilized for new inpatient consults?

The clear choice would be CPT codes 99221-99223, however, the 2009 CPT guidelines for these codes specifically state:

“…codes [99221-99223] are used to report the first hospital inpatient encounter by the admitting physician. For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate.”

Since the inpatient consult codes (99251-99255) have been eliminated by CMS in 2010 and the initial hospital care codes (99221-99223) are only for use by the admitting physician, the only other choice remaining would be to use the subsequent hospital care codes (99231-99233) in place of the new or established inpatient consult codes. The allowable on the subsequent hospital care codes are lower than those associated with the inpatient consult codes and will lead to a decrease in revenues for these services.

CMS has stated, “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.  All other  physicians who perform an initial evaluation on this patient will bill only the E/M code for the complexity level performed.”

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