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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AUDIO: What surgical specialties need to understand about the new consult rules. With Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC.
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Discover what the 5th digit represents and why you need it on your claim.
Question: A presents to the ED with complaints of a headache that’s worsening daily. He is experiencing visual blurring and nausea but no vomiting. This is the third headache of this nature in three weeks, and it has lasted “four or five days.” Documentation indicates a detailed examination and history; after performing the assessment and speaking to the patient, the physician documents migraine with typical aura and status migrainosus Treatment options include acute intervention with prescription, but the physician feels the patient needs to add prophylactic medicine treatments, since the headaches appear to be reoccurring. What migraine ICD-9 code represents this patient’s headache?
Tennessee Subscriber
Answer: This sounds like a migraine with status migrainosus. On the claim, report the following:
- the appropriate-level E/M code based on the notes, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused detailed history; an expanded problem focused detailed examination; and medical decision making of moderate complexity …)
- •346.02 (Migraine with aura; without mention of intractable migraine with status migrainosus) appended to the E/M to represent the patient’s headache
- •368.8 (Other specified visual disturbances) appended to the E/M to represent the patient’s blurred vision
- •787.02 (Nausea alone) appended to the E/M to represent the patient’s nausea.
Explanation: All of the migraine codes now include a fifth digit that indicates presence of status migrainosus. Since your patient reported a four-day migraine, it sounds like the patient was suffering from status migrainosus.
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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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Find out if you’re legal in collecting patient portion before providing the surgical service.
Don’t be too hasty in collecting a patient’s copay and deductible up front.
“While in theory, the practice of collecting deductibles up front may sound good, you should check your carrier contracts to be sure you are allowed to do this before requesting the deductible amount from the patient up front. There are plans which strictly prohibit this type of up front billing, and you can cause quite a headache for your practice if you are not well informed,” warns a subscriber who commented on “Checklist: Collect Surgical Deductibles Up Front to Improve A/R.”
True, says Medical Office Billing & Collections Alert editor Leesa Israel. It is always best to check your payer contract before implementing any billing or collections practice. Every payer, and every contract, can be different.
Whether you can collect a deposit from the patient before performing a surgery is a function of your payer contract that your physician has signed. If the contract does not exclude collecting copays and deductibles up front, you are perfectly legal in collecting the patient portion of the surgery before providing the service.
Exception: If your physician signed a contract that forbids this type of up-front collection, you would be violating the contract by collecting a pre-surgery deposit.
Lesson learned: This is why it is so important to read your contracts before signing them and why it is so important to have a copy of all of your signed contracts. That way, you can quickly and easily determine if there are any limitations or any privileges that you have as stated in the contract that affect your billing and collections procedures.
Download your 2 FREE sample issues of Medical Office Billing & Collections Alert here.
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- 10 Carrier Contract Negotiation Tips Carrier contract negotiation is often a long, difficult process....
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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.
