Coding Strategy

Even though Medicare no longer accepts consult codes, you can still apply modifier 57.

Question: In our ob-gyn office, we used to apply modifier 57 to inpatient consult codes. Now that Medicare doesn’t accept consult codes, how should we use this modifier?

Kentucky Subscriber

Answer: The short answer is that you should appendmodifier 57 (Decision for surgery) to the non-consult inpatient E/M code that the documentation supports.

Suppose the ob-gyn performed a 2009 level-three inpatient consult in which the ob-gyn determined the patient required an exploratory laparotomy later that sameday due to severe abdominal distention and pain as well as some uterine bleeding. Adding the modifier to the E/M code will help show payers why you’re reporting an EM in addition to the major surgery performed later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).

For 2010, the exact E&M code you choose will depend on the circumstances specific to the visit, such as whether the visit is the first or second ob-gyn visit during the admission. But as an example, suppose you’re coding the ob-gyn’s first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity …), which has requirements similar to 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity).

You should append modifier 57 to the E/M code. If, instead, the ob-gyn is the principal physician — the one overseeing the patient’s care and the one who is admitting the patient — be sure to append modifier AI (Principal physician of record), as well. This would be the case if the ob-gyn admitted the patient for observation for the abdominal pain and bleeding but later made the decision to take her to surgery that same day.

@ Ob-gyn Coding Alert, Editor: Suzanne Leder, BA, M. Phil., CPC, COBGC

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Test your 2010 consultation coding understanding with these questions and answers.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by taking this three-question quiz and then checking your answers against the experts’.

Question 1: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Question 2: What modifier do admitting physicians need to use in 2010 when they report an initial hospital care code (99221-99223)?

Question 3: When Medicare is the patient’s secondary insurance and his primary insurance accepts the consultation codes, should you use a consultation code for the Medicare Secondary Payer (MSP) as well?

Answer 1: Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221- 99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the “Not Otherwise Classified” (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

Answer 2: Stick With 2 Letters for Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you’re billing for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code.

This will denote the admitting physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in an orthopedic surgeon to perform a consult for multiple fractures in the patient’s leg. The trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The orthopedic surgeon then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. “Some people are interpreting the new modifier as a ‘one,’” Cobuzzi says. “But it’s two letters, A and I,” she reminds coders. Think: A-eye.

Answer 3: Skip 99241-99255 for Medicare, Even as Secondary

Don’t even think about billing a consult to Medicare — even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultations codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare. The MSP “will not pay for consults,” says Samantha Daily, a medical biller for a practice in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes” you should bill for secondary payment from Medicare in one of the following two ways:

Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or Bill the primary payer using a consult code, and then report the amount paid by the primary payer, and change the code to the non-consult E/M code (that is equal to the consultation code/service documented and paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department.

You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.

@ Medical Office Billing & Collections Alert

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Check your 2010 consultation coding savvy.

Find out if you’re set to properly code your physician’s consultation services this year by tackling three problems and their solutions.

Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221-99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the Not Otherwise Classified (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

Stick With Two Letters for Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you’re billing for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code. This will denote the admitting physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875.

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in an orthopedic surgeon to perform a consult for multiple fractures in the patient’s leg. The trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The orthopedic surgeon then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. “Some people are interpreting the new modifier as a one,” Cobuzzi says. “But it’s two letters, A and I,” she reminds coders. Think: A-eye.

Skip 99241-99255 for Medicare, Even as Secondary

Don’t even think about billing a consult to Medicare — even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultations codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare.

The MSP “will not pay for consults,” says Samantha Daily, a medical biller for a practice in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes” you should bill for secondary payment from Medicare in one of the following two ways:

• Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or
• Bill the primary payer using a consult code, and then report the amount paid by the primary payer, and change the code to the non consult E/M code (that is equal to the consultation code/service documented and paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department. You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.

@ Medical Office Billing & Collections Alert

Be a hero. Join the coding community at the Supercoder Fan Page. There, you can find a FREE webinar from Jen Godreau about consult coding.

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Test your 2010 consultation coding understanding with these questions.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by trying your hand at this question.

Question: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Click ‘read more’ for answer …

Answer: Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221- 99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the “Not Otherwise Classified” (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

AUDIO: What surgical coders need to know about the 2010 consult revisions.

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Plus: You can now download a list of all practitioners who can order/refer.

If you’ve been confused about how to report low-level hospital visits now that consult codes are gone, you aren’t alone. CMS intends to tackle this problem by issuing more specific guidance on the topic in the near future.

That’s according to a Feb. 2 CMS-sponsored Physicians, Nurses, and Allied Health Professionals Open Door Forum, where one practice asked the CMS reps when the agency plans to issue instructions on how to report initial hospital visits when the documentation doesn’t meet the criteria for the lowest level visit, a 99221.

CMS is currently working with the medical community to create such guidance, which will “hopefully be out shortly,” noted CMS’s Whitney May during the call.

One caller indicated that her MAC (WPS Medicare) instructed her to use the unlisted E/M code 99499 when the visit doesn’t meet the criteria of 99221 — but the MAC also said …

it would be inappropriate to report a subsequent care code prior to an initial care code.

That interpretation basically says “that if you don’t meet the initial care code, you have to bill unlisted, but the next day if you don’t meet the initial care code you still can’t bill a subsequent visit because you haven’t billed an initial hospital care code, so you have to bill another 99499,” the caller said. “I understand you’re working on creating guidance on this issue, but what do we do today?”

A CMS rep. advised the caller to follow local contractor guidance until CMS is able to issue a more detailed update. “We’ve been working closely with the medical community to try to develop very clear instructions for how to address this particular situation as well as some other questions that have come to us, and we are very close to having that information completed,” the CMS representative said. “We want to be very sure when we’re putting out information that we’re putting it out only one time and that it’s understood by everyone - so that should be coming out very soon.”

When asked whether the guidance would be issued in “days, weeks, or months,” the CMS rep responded only that CMS is doing its best “to get it out as soon as possible.”

Look for NPI List on CMS Site

CMS also addressed the fact that it had previously committed to sharing a list of all physicians and non-physician practitioners who are eligible to order and refer, and that list is now available on the Medicare provider enrollment web page at www.cms.hhs.gov/MedicareProviderSupEnroll, said said Patricia Peyton from CMS’s provider supplier enrollment office, during the call.

Once on the Web site, click on “ordering and referring report.” The .pdf file includes about 800,000 practitioners, their NPI numbers, and their last and first names.

Phase two of the ordering and referring edit starts on April 5, “and what happens then is every claim for an ordered or referred service, when it goes to be processed, if that ordering or referring provider does not pass the two edits, which are to have a current enrollment record and to be of the type that can order and refer,” then that claim will be rejected, Peyton said.

If you review the file and you don’t find your name but think you should be there, “contact your Medicare enrollment contractor,” she indicated.

One caller said that their organization submitted an application for a new provider, but was concerned that any services the provider orders during that period (such as diagnostic lab, radiology, or DME items) will be denied while CMS is waiting to process the certification application.

“We know that the applications can’t be processed overnight,” Peyton said. Once the physician is in PECOS, that supplier can resubmit the claim. “The supplier is not going to look at the date the provider enrolled, as long as the provider’s on the PECOS file that the claims processors use, and everything else is ok with the claim, the claim will then be paid.”

@ Part B Insider

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