Coding Strategy

Grasping 93010’s effect on new vs. established patient status could bring a $58 reward.

Whether you call them ECGs or EKGs, chances are you see a lot of electrocardiograms in your practice. That means that even the tiniest coding errors can add up quickly. Brush up on the 93000-93010 basics with this review of the service, the code components, and the role ECGs can play in choosing the proper E/M code.

1. Count on These Codes for Proper ECG Reporting

There are three codes for routine ECG:

• 93000 — Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
• 93005 – … tracing only, without interpretation and report
• 93010 — … interpretation and report only.

The service these codes describe typically involves placing six leads on the patient’s chest and additional leads on each extremity, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash. The procedure “picks up and traces the path of electrical activity sent from the SA [sinoatrial] node through the heart and puts it onto paper,” Neighbors says.

The external skin electrodes can pick up electrical current because the heart’s electrical activity generates currents that spread to the skin, explains CPT Assistant (April 2004).

2. Prevent Denials With This Modifier 26 Rule

Just say no to modifier 26 (Professional component) with your ECG code, warns Kim Huey, CPC, CCS-P, CHCC, an independent coding consultant in Auburn, Ala. Similarly, you should not append modifier TC (Technical component).

Reason: Codes 93000-93010 are already broken down into professional and technical components, Huey says:

• 93000: global (professional and technical components)
• 93005: tracing (technical component)
• 93010: interpretation and report (professional component).

In other words, if the cardiologist provides only the interpretation and report for an ECG performed at a hospital, you should report 93010, not 93000-26.

Helpful: If you ever need a reminder about whether a code accepts modifiers 26 and TC, the Medicare physician fee schedule (MPFS) can help. According to the MPFS, 93000 has a PCTC (professional component, technical component) indicator of “4,” meaning “global test only” code. Code 93005’s PCTC indicator is “3,” which indicates “technical component only” code. And 93010’s indicator of “2” means the code is a “professional component only.” You can search the MPFS at www.cms.hhs.gov/pfslookup/.

3. Pinpoint Whether 93010 Patients Are ‘New’

Your cardiologist’s role in an ECG interpretation could dictate whether you choose a new or established patient E/M code at the patient’s next visit.

Rationale: “An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient,” states Medicare Claims Processing Manual, Chapter 12, Section 30.6.7 (www.cms.hhs.gov/Manuals/).

You just need to be sure you understand the definition of a new patient, says Betsy Nicoletti, MS, CPC, founder of Medical Practice Consulting in Springfield, Vt. A new patient is one who has not received professional service from that physician (or another physician of the same specialty in the same group) during the past three years.

Medicare’s decision to no longer cover consult codes makes mastering new versus established even more important. Your consult code choice did not differ based on whether a patient was new or established, but the codes you use to replace the consult might. For example, consult codes 99241-99245 specify: “Office consultation for a new or established patient …” In contrast, office/outpatient E/M codes 99201-99205 are for new patients only and 99211-99215 are for established patients only.

Payoff: If documentation supports coding a visit previously reported as a consult as a level-five E/M service, for example, knowing the difference between new and established has an impact on your wallet. The Medicare nonfacility national rate for a level-five new patient visit (99205) pays $58 more than a level-five established patient visit (99215).

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In MSP cases, non-consult code for both payers may be best.

If you have payers who didn’t play follow-the-leader with Medicare in cutting out consult codes, you have a dilemma on your hands. You have to decide what to do when your physician performs a consult, the primary insurer pays you for the service, and Medicare is the secondary payer.

Map Out a Strategy From MLN Article

CMS announced the “Medicare Secondary Payer (MSP) will not pay for consults,” says Samantha Daily, billing specialist with a practice in Portland, Ore.

Recently published 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 in one of the following two ways:

• Bill the primary payer an E/M code, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due.
• Bill the primary payer using a consult code, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

“The first option may be easier from a billing and claims processing perspective,” indicates CMS in the MLN Matters article.

Choose the Option That Works for You

“There is essentially no workaround for this situation, so you have to decide whether you will get paid better via payment from the primary insurer with a consult code versus the alternative (billing an E/M to both payers),” says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Consulting located in West Chester, Pa.

Potential snag: In some cases, such as a physician seeing a hospital patient, the doctor may not know whether the patient is on Medicare or has a different insurer when he documents his consultation. Coders will need to be able to glean an appropriate E/M code from the physician’s consult documentation if the patient ends up being on Medicare.

To read the MLN Matters article on the consult elimination, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.

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Have more consult questions? Attend expert Barbara Cobuzzi’s Revisions to Consultation Services Payment Policy for Surgical Specialties April 14 audioconference.

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.

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Check with Medicaid plans, insurer warns.

You can breathe a sigh of relief — one major payer will stick with 99241-99255.

UnitedHealthcare (UHC) commercial plans will make no change in payment for consultation codes (99241-99255) at this time, according to a UHC e-mail alert. “Physicians may continue to submit claims for these services, and will be reimbursed according to United-Healthcare payment policies”.

Beware: One Medicaid plan will eliminate consult pay and force you to follow Medicare’s rule of using office and hospital codes in lieu of 99241-99255. “For AmeriChoice Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS rules and implement the change effective January 1, 2010,” the email notice states. “For all other Medicaid states, AmeriChoice will follow the  UnitedHealthcare commercial position and continue to pay for the consult codes, until directed otherwise by a state to pursue other strategies.”

Watch your mail for a UHC payer news notice and an article in the January Network Bulletin.

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Ever used an unlisted E/M code? Get ready.

By now, you’ve heard that CMS is doing away with all inpatient (99251-99255) and outpatient (99241- 99245) consultation codes in 2010 — but are you prepared for the issues this may cause, starting Jan. 1? Ask these three questions of your practice and payers, and you’ll fend off headaches before they start.

Keep in mind: While Medicare has released the transmittal letter to all carriers instructing them about the policy change to no longer payer for consultations, Senator Arlen Specter (D-PA) introduced an amendment to the Patient Protection and Affordable Care Act (H.R. 3590) to delay this policy change by one year. This amendment was added on Dec. 14, 2009.  If Congress does not pass this bill before the end of the year, the Medicare policy will go in as planned.  Check the Ob-gyn Coding Alert and SuperCoder for more developments, but be prepared just in case.

1. Do Medicaid and Private Payers Have Consult Advice?

If a physician sends a Medicare patient to your ob-gyn for a consultation, you should use regular E/M codes (99201-99215, Office of other outpatient visit for a new or established patient …) instead. But what about the other insurers?

“We have to remember that right now, this is just Medicare,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis., who led the “Consultations” session at the 2009 Ob-Gyn Coding & Reimbursement Conference in Orlando.

Medicaid and private payers may follow suit — or they may not have even learned of CMS’s decision. “Four weeks ago, I asked a secondary insurance company what they were doing about the consultation issue, and their response was, ‘Huh?’” laments Rasmussen.

2. What Happens If Admitting Physician Forgoes Mod AI?

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

Translation: An emergency room (ER) doctor sees a patient who was involved in a motor vehicle accident. He calls in a trauma surgeon because of possible intra-abdominal damage, and the trauma surgeon admits the patient because of possible bleeding. The patient is pregnant, so the ob-gyn comes in for a consultation also. Trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The ob-gyn then bills 99221-99223 with no modifier.

Problem area: If the admitting physician does not include modifier AI, then the payer is receiving two initial hospital care claims for the same patient on the same day. CMS Transmittal 1875 acknowledges, “As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.” What is not clear is what to do when the admitting physician makes the mistake and your ob-gyn has submitted the claim correctly. “At this point, we’re not sure if this will cause a concurrent care issue,” Rasmussen says.

Here’s another concern. Suppose your ob-gyn does a consultation in an observation setting. Your ob-gyn will have to use an outpatient office code, but the new guidelines do not include observation codes (99217-99220) as requiring modifier AI identifying the admitting physician. Again, will this cause a concurrent care issue? If so, you better be prepared to fight for your claim.

On top of that, will your private payers even accept modifier AI if they are the secondary payer? This remains to be seen.

3. What About Hospital Inpatient Levels?

Instead of consultation codes, CMS directs you to use initial hospital care codes (99221-99223), but you have a problem. Consultation codes have five levels whereas initial hospital care codes have only three.

Requirements: Part of the rationale behind deleting consultation codes is that physicians were not meeting the level of service requirements. “When two of the three initial hospital care codes require nothing less than a comprehensive history and comprehensive exam, I’m not sure how the deletion of the consultation codes will correct these kinds of errors,” Rasmussen says.

Did you know the lowest initial hospital care code (99221) requires a detailed history and detailed exam? Most physicians “don’t get there,” Rasmussen says. In order to reach a detailed history, your physician must document an expanded HPI, review of 2-9 systems, and pertinent past, social or family history. While this level of history is not difficult to document, the physician must document a detailed exam. In support of that level of exam, you must have an evidence of an extended exam of the affected system plus 2-7 related organ systems or body areas if using the 1995 guidelines.

If you’re using the 1997 guidelines, your physician must document 2 bulleted elements from 6 systems or at least 12 bulleted elements from the GU single system exam. Many physicians don’t do this level of examination at the time of the inpatient consultation. because it may not be medically indicated.

When you don’t get to even this level (and you would’ve qualified for a level one or two initial hospital care code, if it existed), your only option is to report 99499 (Unlisted evaluation and management service). “The problem with this is that this claim will automatically go into review,” Rasmussen says. “This year’s CPT Symposium Board had no solution but realized they needed to address this.”

Be Pro-Active and Take Action to Find Answers

Even though Jan. 1 will have come and gone by publication date, you need to know the solutions to these issues. “Watch carrier bulletins,” recommends Rasmussen. Find someone who can clarify, in writing, how they want these services reported. “Harass them for answers!”

Note: Check back with the Ob-gyn Coding Alert for more minefields in the transition from consultation to E/M codes.

To obtain a CD of this year’s Ob-Gyn Coding & Reimbursement conference, go here or call 1-866-251-3060.

To view the video, click the link below

Ask 3 Questions to Head Off 2010 Consult Problems

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