As with all billable services, you should ensure that the criteria required by the payer you are billing have been met. CPT also directs that the written request for consultation can be documented by either the requesting or the receiving physician—something that was unacceptable under Medicare guidelines.
Last, CPT has added instructions to clarify the type of consultation code to bill under certain circumstances:
- When the patient is admitted after an outpatient consultation but the physician does not see the patient on the unit on the date of admission, bill only for outpatient consultation
- When the patient is seen for an office visit, emergency room visit, or outpatient consult on the date of admission and the physician then sees the patient on the unit that day, bill only the inpatient consultation or initial hospital care code, whichever applies. All services that day are used to determine the final level of service.
Medicare tilts the playing field on consultations
Although CPT has retained all consultation codes, and although the hope is that commercial payers will continue to reimburse for such services in the near future, the big news is that Medicare has announced that it will no longer recognize (or reimburse for) codes for outpatient or inpatient consultations. (Note: This story is still unfolding, however. The changes announced by Medicare that I discuss below are still before Congress as this article goes to press. Although Medicare has, in fact, released the transmittal letter to all carriers instructing them about the changes, Senator Arlen Specter [D-Pa] has introduced an amendment to the Patient Protection and Affordable Care Act [H.R. 3590] to postpone the policy change for 1 year. If Congress has not passed this bill before the end of 2009, the changes go through as planned. Stay tuned for developments!)
Assuming the changes go through, here is what is expected of you in the circumstances of providing consultations and billing Medicare (Medicaid payers aren’t required to follow this policy change but may opt to do so).
Outpatients. Document, and report, the appropriate level of visit for a new or established Medicare patient using outpatient codes 99201–99215
Inpatients. If you are a non-admitting physician asked to see a patient for the first time, report the appropriate level of initial hospital care (codes 99221–99223). Note the following three points:
- Initial hospital care includes only three levels of service—not the five levels from which you choose for consultation codes
- The lowest level of history and exam for these initial visit codes is a detailed history and examination—no matter the level of medical decision-making. If the level of history or exam is documented lower than “detailed”—say, as “expanded problem-focused”—you are required to report the unlisted E/M code 99499.
- The admitting physician adds the new Healthcare Common Procedure Coding System (HCPCS) modifier –AI (that is, “‘A’ upper-case ‘i’”) to the initial visit code, so that Medicare can distinguish the admitting physician from others providing care for the patient.
- All subsequent visits with the inpatient continue to be billed with the subsequent care inpatient codes (99231–99233).
Fallout from this change? Medicare is studying the implications of its new policy on secondary payments—that is, when Medicare is the primary payer and there is a supplemental carrier, or when Medicare is the secondary payer. Note: Medicare strongly advises all providers to check with their primary payers, because 1) Medicare will not accept a consultation code when a primary insurer has paid on that code and 2) it’s doubtful that a commercial payer will accept a consultation code when Medicare has paid for a new or established patient service.
To add to the turmoil…
The CMS has announced that, as a result of the changes in Medicare policy on consultations, it is increasing the relative values for all new and established patient services and initial hospital care. CMS is doing this, however, by reducing the relative values of some consultation codes.
In addition, all surgical procedure codes that carry a 10- or 90-day global period will see an increase in work RVU because of the increase in E/M services that are a part of all global care. Keep in mind that payers who use the Resource-Based Relative Value Scale (RBRVS) to reimburse services will probably adopt the new values when contracts are up for renewal, although many will be unable to do so in the short term.
It also remains to be seen if any commercial payers adopt Medicare policy or continue to pay for consultations. This area might be a contract issue with payers.