Public Policy

Consultation Elimination

As of Jan. 1, the Centers for Medicare and Medicaid Services (CMS) ceased physician payment for consultations. The elimination of consult codes will affect physician group payments as well as relative-value-unit (RVU)-based incentive payments to individual physicians.

The Medicare-designated status of outpatient consultation (99241-99245) and inpatient consultation (99251-99255) codes has changed from “A” (separately payable under the physician fee schedule, when covered) to “I” (not valid for Medicare purposes; Medicare uses another code for the reporting of and the payment for these services). So if you submit consultation codes for Medicare beneficiaries, the result will be nonpayment.

While many physicians fear the negative impact of this ruling, hospitalists should consider its potential. Let’s take a look at a scenario hospitalists encounter on a routine basis.

FAQ

Q: How do hospitalists handle claim submission to third-party payors given Medicare’s determination to stop utilizing consultation codes?

Answer: While there is suspicion that some of the major third-party payors will follow Medicare’s ruling, nothing has been published as of press time. Until confirmed, third-party payors still recognize consultation codes as outlined in contractual agreements with physician groups.

Nevertheless, hospitalists may be obligated to report the same code to primary and secondary payors. Medicare will not allow you to change the code on the claim when they are the secondary payor. Third-party payers may have similar prohibitions in their contractual agreements when they are the secondary payor.

More specifically, CMS states, “In cases where other payors do not adopt this policy, physicians and their billing personnel will need to take into consideration that Medicare will no longer recognize consultation codes submitted on bills, whether those bills are for primary or secondary payment. In those cases where Medicare is the primary payor, physicians must submit claims with the appropriate visit code in order to receive payment from Medicare for these services. In these cases, physicians should consult with the secondary payors in order to determine how to bill those services in order to receive secondary payment. In those cases where Medicare is the secondary payor, physicians and billing personnel will first need to determine whether the primary payor continues to recognize the consultation codes.

If the primary payor does continue to recognize those codes, the physician will need to decide whether to bill the primary payor using visit codes, which will preserve the possibility of receiving a secondary Medicare payment, or bill the primary payor with the consultation codes, which will result in a denial of payment for invalid codes.4 Problems are expected during the transition period as practices deal with coding variances that will affect physician reimbursement, as well as coinsurance and deductibles. Look for further guidance from payors as this issue unfolds.—CP

Typical HM Scenario

A surgeon admits a 76-year-old man for aortic valve replacement. The patient’s history also includes well-controlled hypertension and chronic obstructive pulmonary disease (COPD). Postoperatively, the patient experiences an exacerbation of COPD related to anesthesia, elevated blood pressure, and hyperglycemia. The surgeon requests the hospitalist’s advice on appropriate medical interventions of these conditions. How should the hospitalist report the initial encounter with this Medicare beneficiary?

The hospitalist should select the CPT code that best fits the service and the payor. While most physicians regard this requested service as an inpatient consultation (99251-99255), Medicare no longer recognizes those codes. Instead, the hospitalist should report this encounter as an initial hospital care service (99221-99223).

Comanagement Issues

CMS and Medicare administrative contractors regularly uncover reporting errors for co-management requests. CMS decided the nature of these services were not consultative because the surgeon is not asking the physician or qualified nonphysician provider’s (NPP’s) opinion or advice for the surgeon’s use in treating the patient. Instead, these services constituted concurrent care and should have been billed using subsequent hospital care codes (99231-99233) in the hospital inpatient setting, subsequent NF care codes (99307-99310) in the SNF/NF setting, or office or other outpatient visit codes (99201-99215) in the office or outpatient settings.1

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