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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Beware: Don’t use the CMS consult crosswalk for billing purposes.

You may be seeing light at the end of the tunnel. The AMA just published an article to clarify the use of the consultation codes for non-Medicare patients, and talks about their efforts to get CMS to delay their new policy. You can find the article here.

Watch out …The link that was provided for the so-called CMS consult crosswalk is not a crosswalk for billing purposes. CMS used the information to assess how to redistribute the relative values to the new and established E/M outpatient codes (99201-99205, 99212-99215) as well as the initial hospital codes (99221- 99223). This means it has absolutely nothing to do with coding. You need to determine the level of service based on what is documented, not what it might have been had you reported the consult codes (they are no longer in the picture).

The same rule applies for the initial hospital visit. If the physician has not documented a detailed history and exam at a minimum, or documented total time of 30 minutes of which 15 or more minutes was counseling, you cannot report an initial hospital code. Under CMS rules, you would have to bill 99499 (Unlisted evaluation and management service). That means your claim will automatically go into review.

Update: CMS is meeting to discuss the matter and other billing issues that have arisen because of the new policy. Check back with the Coding News or go to www.supercoder.com.

AUDIO: What surgical specialties need to know about consultation reimbursement changes in 2010.

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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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