Instructions on CMS' Consult Changes
December 20, 2009
CMS has just released instructions on consult changes.
One thing you must know is that if you admit or oversee a patient's care during a hospital or nursing facility stay then you must add modifier AI (principal physician of record) to initial inpatient care codes (99221-99223, hospital and 99304-99306, nursing facility). All other physicians who perform an initial evaluation of the patient will bill with the appropriate E/M code.
National Government Services should not reject claims when modifier AI is added to a subsequent care or outpatient visit code.
Program Transmittal 1875 to the Claims Processing Manual gives more details on how to bill for services once CMS stops paying for consult codes on January 1, 2010 (99241-99245, outpatient and 99251-99255, inpatient).
Please click on the following link to access Program Transmittal 1875 to the Claims Processing Manual:
The North Shore Physician Organization is planning a coding and documentation seminar. We will be sending out a notice within the coming weeks.
CMS Eliminating Medicare Payments for Consultation Codes
On January 1, 2010, CMS will no longer pay physicians if they submit claims with consultation codes in the 99241 - 99245 or 99251 - 99255 series. CMS said the reason for this was because of the difficulty in differentiating a consult from other E/M services.
(Note: For the time being, consultation codes continue to be valid for all other payers, e.g. managed care and other commercial insurers including Medicare Advantage plans.)
According to CMS this will be budget neutral but not necessarily to your practice. CMS has increased RVU's for New and Established Patients by 6% and for Initial and Subsequent Hospital Visits by 2%. This will result in an income increase for primary care specialties, and a decrease for specialists who use consult codes.
Reimbursement for lower-level initial hospital care visits will be increased compared to lower-level consultation codes but you'll need to brush up on documentation for billing E/M visits in order to get paid.
It is important for physicians to know the requirements for billing E/M codes, including initial hospital care (99221-99223). CMS clearly states "physicians will bill an initial hospital care or initial nursing facility care code for their first visit during a patient's admission to the hospital or nursing facility in lieu of the consultation codes these physicians may have previously reported."
When compared to other specialties such as cardiac surgery, specialties such as orthopedic surgery, dermatology, podiatry, hand surgery, Ob/Gyn and urology that bill a higher percentage of low-level inpatient consultation codes
(99251-99252), than high-level codes (99254-99255), will be the most adversely affected financially. It is important that you check your own billing data to determine if you bill the lower-level inpatient consult codes. Low-level initial hospital care code 99221 ($89.81) requires a greater level of effort than what a physician is used to performing for a 99251 ($48.69).
According to the CPT Handbook, a 99251 requires the following three elements:
1. A problem focused history;2. A problem focused examination; and
3. Straightforward medical decision making.
A 99221 requires these three key elements:
1. A detailed or comprehensive history;2. A detailed or comprehensive examination; and
3. A medical decision making that is straightforward or of low complexity.
Physicians will have to increase their documentation and show they performed more examination elements. But keep in mind, if a physician does a comprehensive exam instead of a problem focused exam every time, then it will come down to the question of why that exam was performed and was it medically necessary.
NSPO Honors NYS AG Andrew Cuomo
On October 28, 2009, Dr. Tom Mauri (left), president of the NSPO, and Dr. Simon Prince (right), president of the NSUH Staff Society presented NYS AG Andrew Cuomo with a plaque in recognition of his outstanding leadership and for safeguarding the rights of patients and the medical community at large.
Cuomo was at NSUH to announce the creation of a new database that will be operated by a New York nonprofit called FAIR Health which insurers will use to determine their reimbursement rates for out-of-network care and will inform consumers and physicians on what to expect their policy to pay when seeking such care.
Cuomo thanked the NSPO physician leaders for being the first to brief him on this issue back in 2007 and for answering his questions about Ingenix and UCR rates. Last year, Cuomo announced that he was conducting an industry-wide investigation into a scheme by health insurers to defraud consumers by manipulating reimbursement rates. At the center of the scheme was Ingenix, Inc., the nation’s largest provider of healthcare billing information, which served as a conduit for rigged data to the largest insurers in the country. The Attorney General’s investigation found that by distorting the “reasonable and customary” rate, the insurers were able to keep their reimbursements artificially low and force patients to absorb a higher share of the costs. The investigation resulted in $100 million in settlements with all of the major health insurers.