By Jeannie Cagle, RN, CPC, Manager

Centers for Medicare & Medicaid Services (CMS) has announced they will no longer pay physicians for codes in the 99241-99245 (outpatient consultation) or 99251-99255 (inpatient consultation) series.  After years of education and clarification, they were finally fed up and eliminated payment for the codes altogether. The ruling is spelled out in the Federal Register ([FR Doc. 2009-26502 Filed 10/30/2009 at 4:15 pm; Publication Date: 11/25/2009], available at http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf.

CMS has increased the Relative Value Units (RVUs) for new and established patients by 6% and for initial and subsequent hospital visits by 2%, technically declaring the consult code elimination as “budget neutral.” Obviously, this will result in an income increase for primary care specialties, and a decrease for specialists who use consult codes. The difference between a new patient visit and a consult was far greater than 6%. What will specialists use now when they see a patient? In the office, they will use a new or established patient code (99201-99205, 99211-99215), depending on whether or not the patient has been seen in the practice by that physician or another of the same specialty in the past three years. The bad news will be for a specialist who sees a patient that saw one of their partners within the three years for an entirely different problem but the same specialty (for example, an orthopedic practice that sees the patient for a rotator cuff tear in 2007 and a knee replacement in 2009).

In the hospital, each physician who sees a patient will bill for an “initial hospital service” (99221-99223) no matter what day of the hospital stay the patient is seen. The admitting physician will add a modifier (not yet published by CMS) to their initial hospital service, allowing the Medicare carrier to tell the difference between the admitting physician and other physicians providing care. All physicians will use the subsequent visits for their follow up care.

What about your commercial insurances? The consult codes are in the 2010 Current Procedural Coding (CPT®) book, and each insurance will have to determine their policy about consult codes. It will be important for you to ask each one how they want you to handle consults in 2010. Other factors to consider will be how to handle secondary Medicare insurance, as it won’t pay on a consult that has been paid by the primary insurance. Also, the previous requirements of written correspondence won’t be required by the new patient codes, so communication with the Primary Care Physician (PCP) in the outpatient setting will be done by the specialist out of courtesy to the PCP, and not obligation. 

It is imperative that you communicate these new guidelines to your physicians as soon as your billing staff has determined the policies for your other insurances so they will understand the new billing requirements for CMS beginning January 1, 2010. Please contact Coker Group at  jcagle@cokergroup.com if we can help you in any way.

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