Coding Strategy

Medicare’s elimination of payment for consultation services has caused mass confusion throughout the coding community, not just due to the changes it has caused in your billing procedures, but also due to lack of information from CMS.

In an apparent attempt to quell those issues, CMS has released MLN Matters article SE1010, which offers several questions and answers regarding how to report your services now that Medicare no longer recognizes consult codes (99241-99255).

For example, CMS addresses the often-asked question of whether the agency will release a crosswalk of  consult codes to E/M codes. “No,” CMS responded in the article. “Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished.” In other words …

You must report the E/M code that best matches your provider’s documentation, rather than attempting to find the appropriate consult code and matching it to an office or hospital visit code.

Plus: Many providers have been concerned about what will happen if  they report a subsequent hospital care code (99231-99233) for a physician who hasn’t first billed an initial hospital care code (99221-99223).

CMS responds that it has instructed MACs “to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met,” even if that provider is seeing that patient for the first time during his or her hospital stay.

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Here are the requirements the exam must meet, according to Medicare.

If your PET claim meets certain requirements, you don’t need to append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), according to MLN Matters article MM6753.

Effective for dates of service on or after Nov. 10, 2009, Medicare has an updated national coverage determination (NCD) for cervical cancer FDG PET imaging. Medicare has ended the coverage with evidence development (CED) requirements for initial staging of initial treatment.

Medicare will cover one FDG PET for cervical cancer. That one exam must meet specific requirements:

• The exam must be for staging (not initial diagnosis).
• The patient must have biopsy proven cervical cancer.
• The treating physician must need the study to determine the tumor’s location, extent, or both for one of the following therapeutic purposes related to initial treatment strategy:
• To determine whether the beneficiary is a candidate for an invasive diagnostic or therapeutic procedure
• To determine the optimal anatomic location for an invasive procedure
• To determine the tumor’s anatomic extent when the recommended anti-tumor treatment depends on that information.

Codes: Your claim must include all of the following for reimbursement:

• An appropriate CPT code from 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation), 78811-78813 (Positron emission tomography [PET] imaging …), or 78814-78816 (Positron emission tomography (PET) with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging …)
• Modifier PI (PET Tumor initial treatment strategy)
• A cervical cancer diagnosis code (such as 180.x, Malignant neoplasm of cervix uteri).

Action step: The effective date of this policy is Nov. 10, 2009, but the implementation date is Jan. 4, 2010. Carriers won’t search their files for PET cervical cancer claims for Nov. 10 to Jan. 3 dates of service, but they will adjust those claims that you bring to their attention.

Resources: To learn more, check out Transmittal 110, Change Request 6753.

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If you bill consults to private payers, good luck collecting the balance from Medicare secondary payers.

Don’t even think about billing a consult to Medicare — even if it’s only a secondary payer claim. Medicare may have scratched consultations off of its list of payable services, but many other insurers did not follow suit. This leaves you in a quandary when your physician performs a consult and the primary insurer pays you for it, but Medicare is the secondary payer.

“Medicare Secondary Payer (MSP) will not pay for consults,” says Samantha Daily, billing specialist with Urologic Consultants, PC in Portland, Ore. She points coders toward MLN Matters article MM6740, which 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. 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; or

• 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.

CMS indicates in the MLN Matters article that “the first option may be easier from a billing and claims processing perspective.” “There’s essentially no workaround to 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 in West Chester, Penn.

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. “Medicare has created a genuine mess, and unfortunately there are providers now who have simply informed their staff that they will no longer accept consult requests on Medicare patients, that if a Medicare patient is referred for a consult they’re not available,” Burleigh says.

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