Coding Strategy

Plus: CMS reps cite current Medicare law and advise that practices should report just one inpatient care code per patient, per day.

Although CMS has eliminated payment for consult codes, it will continue to honor split/shared visits — as long as they are billed using E/M codes and follow the payment rules already in place.

That’s the word from CMS, where staffers aimed to straighten out confusion stemming from the January MLN Matters article SE1010, which offered several questions and answers regarding how to bill Medicare following the elimination of consult code payment.

In the article, CMS noted that “the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes.”

“We understand that this has caused some confusion, as there were — and are — different split/shared rules for consultation services compared to E/M services,” noted CMS’s Rebecca Cole noted during during an April 13 CMS Open Door Forum.

“We’d like to clarify that Q&A,”Cole said. “As we’re no longer recognizing the consultation CPT codes for purposes of payment under Part B, the split/shared rules regarding consultation services are no longer applicable. Since E/M visit codes are being billed for services that were previously reported by the CPT consultation codes, the split/shared rules pertaining to E/M services apply when billing E/M CPT codes,” Cole stressed.

Remember: You can still report shared/split visits according to the regulations using E/M codes, but you cannot collect from Medicare for any consultation codes.

CMS is considering issuing a clarification in writing to dispel any confusion regarding the shared/split billing rule, Cole noted.

CMS Advises Practices to Rein in Initial Inpatient Billing

One caller wanted clarification on billing for hospital care now that consult codes aren’t payable. She asked whether a physician can report two initial hospital care codes for the same patient on the same date — for instance, if the physician saw the patient prior to surgery for one reason, and then saw the patient after surgery for another reason.

“I think you should consult the CPT rules as well as the manual, but I think our reaction to that is no,” said CMS’s William Rogers, MD,during the call. The initial hospital care codes refer to that physician’s first visit with the patient, Rogers said. Later evaluations should be billed using subsequent hospital care codes, he advised.

However, CMS reps indicated that they will look into the issue further to determine whether physicians should be able to report a second initial hospital care code if specifically requested to review a different condition. “We can consider this further and decide what our next steps will be,” Rogers said. Until then, CMS staffers urged practices to continue billing according to published rules.

In black and white: “Both initial inpatient hospital care codes and subsequent hospital care codes are ‘per diem’ services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice,” notes CMS Transmittal 1545.

Use Current Bone Density Codes

One caller was delighted that, thanks to the new health care reform legislation, CMS will be raising payment for bone density tests, but noted that the legislation listed old bone density test codes 76075 and 76077.He asked whether MACs will be requesting those codes going forward, or whether practices should continue reporting newer codes 77080-77082.

Advice: You should use the current codes 77080-77082, not the old codes, said CMS’s Amy Bassano.

@ Part B Insider, Editor: Torrey Kim, CPC

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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.

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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