Medicare Eliminates Consultation Codes in 2010 – Adds Modifier to Distinguish Providers

This is going to be fun to say the least to figure this one out unless commercial insurers adapt and follow Medicare. This is especially tricky if Medicare is the second payer. If you are a specialist, this could be a bit of a hit on the pocketbook. Medicare is to provide a modifier to help out. The consultation codes will be recognized but the payment codes will now be marked as not valid for Medicare. The modifier to be provided will help determine the difference between an admitting provider and the one overseeing the patient’s care, who could be a specialist.

99241-99245 (outpatient/office) and 99251-99255 (inpatient) are gone for 2010 for Medicare claims.

Office visits may stand to be further expanded possibly. Anyway, you can read the advice below from this article in Medscape and some additional advice from a related article. BD

The announcement that Medicare will no longer pay for consultation codes shocked the medical industry, leaving doctors worried about their income and perplexed about how to handle the new situation.

The change will certainly affect specialists who rely on the payment differentials -- 20%-30% -- between visit and consult codes. To offset the elimination of office consult payments, the Centers for Medicare & Medicaid Services (CMS) will increase the work relative value units (RVUs) for new and established office visits by about 6% and the work RVUs for initial hospital and facility visits by approximately 0.3% to reflect the elimination of the facility consultation codes.

In 2010, if you perform a consult in the office, choose an office visit code -- new (99201-99205) or established (99211-99215). In the hospital, the code selection process gets a bit more interesting. Consider that opinions are sought for many hospital patients, and those services have long been coded as consultations. This will change in 2010 for Medicare patients. CMS states that "physicians will bill an initial hospital care or initial nursing facility care code for their first visit during a patient's admission to the hospital or nursing facility in lieu of the consultation codes these physicians may have previously reported." This will be the case even if someone else admitted the patient.

From a coding perspective, admitting a patient could get tricky. CMS will create a new modifier for admitting physicians to append to the Current Procedural Terminology (CPT®) code: The modifier will be used to identify the admitting physician of record for hospital inpatient and nursing facility admissions. "This modifier will distinguish the admitting physician of record who oversees the patient's care from other physicians who may be furnishing specialty care."

To explain the controversial move, CMS pointed to physicians' problems in complying with Medicare's consult code guidelines. http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf

A related article offered these suggestions:

1. Consultation codes 99241-99245 (outpatient/office) and 99251-99255 (inpatient) have been eliminated. Tele-health consultation G-codes (G0425-G0427) will not be eliminated.

2. Use codes for new (99201-99205) or established (99211-99215) patients to replace consultations in the office/outpatient setting.

3. Codes in the inpatient hospital setting (99221-99223) should be used to replace inpatient consultation codes (99251-99255), and for nursing facility consultations use codes (99304-99306).

4. To distinguish the difference between the admitting physician of record from the consultants for initial hospital inpatient and nursing facility admissions, Medicare will develop a modifier. Check with your local carrier for more information.

5. Payments for all Evaluation and Management codes have been increased in an attempt to offset the fees lost from the elimination of consultation codes.