Q: Does the recent elimination of consultation codes affect my reimbursements from Medicare in a negative way?

A: Maybe. The Center for Medicare & Medicaid Services reports in the Medicare Learning Network's MLN Matters MM6740 that the change does not increase or decrease Medicare collective payments; it is budget-neutral. Nevertheless, specialists will see a significant reduction in their Medicare payments while generalists will see a small increase. CMS increased the work relative value units for office visit codes (new and established) and for initial facility visits (hospital and nursing facility) and considered the increased use of these services in the final calculation of practice expense and malpractice expense.


Have commercial payers also eliminated their consultation codes?

A: Only some have. The decision to continue to pay for consultations rests solely with the individual third-party payers. We expect many will follow Medicare's lead, and some already have.


Are Medicare Advantage plans required to eliminate consultations?

A: No. Many continue to recognize these consult codes while some have assumed Medicare's position and eliminated them.

Q: May I choose an ophthalmology code for a visit previously coded with a consultative code?

A:Yes. Visits previously coded as outpatient consultations should be coded with the appropriate evaluation and management code (992xx) based on the amount of history, exam and decision-making. Ophthalmologists and optometrists may also utilize the
eye codes (920xx) if the visit satisfies their criteria.


If a patient seeks my opinion and has previously seen me, may I bill him as a new patient?

A: No. Consult codes did not differentiate between new or established patients. In the absence of the consult codes, you must follow the definition for new patients. A new patient is described in the CPT manual as one who has not received any professional services from the physician—or another physician of the same specialty in the same group practice—within the past three years.


Will Medicare recognize the consultation codes for Medicare secondary payer claims?

A: No. You must bill a Medicare-accepted code for the services provided. Physicians may choose to bill an E/M or eye code to the primary payer, which will be recognized for MSP. Or, bill the primary payer a consult code and then change to an appropriate eye or E/M code and file to Medicare for secondary payment.

One notable change is that a written report back to the referring provider is no longer required, but CMS recommends that you continue this etiquette to support coordination of care among physicians and maintain the quality of patient care.


If I provide a consultation to an inpatient in a hospital or nursing facility and he is a Medicare patient, what codes apply?

A: The codes recommended for use are inpatient admission codes 99221 thru 99223 for hospital services and 99304 thru 99306 for patients in a nursing facility.


I'm not the admitting physician; will my claim be recognized with the initial
hospital/nursing facility admission codes?

A: Yes. CMS created a new modifier to be used by the admitting physician. Modifier "AI" appends to the initial inpatient E/M services billed by the admitting or attending physician who's overseeing a patient's care during an inpatient stay in a situation where other providers are also seeing the patient. The consulting physician does not use this modifier.


How do we code for services that do not meet one of the three levels of inpatient admit codes?

A: CMS published in its MedLearn Matters SE1010 that there is no exact match for low-level inpatient consult codes to the inpatient admit codes.  It instructs physicians to use subsequent hospital care CPT codes 99231 and 99232.

You may also use an ophthalmology code in an inpatient setting. Some payers may deny these initially, but unlike E/M codes, the eye codes are not place-specific. The place of service on the claim must match the location where the service was rendered. The site of service reduction applies.



Q: Do these new rules alter the claims for same-day care?

A: No. Same-day care means two physicians in the same group practice see the same patient on the same day for the same reason. The instructions found in the Medicare Claims Processing Manual at §30.6.5 state: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician, or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level."


Is an optometrist in a group practice considered a different specialty, allowing for two visits to be filed on the same day?

A: Medicare considers optometry to be a separate specialty and it is possible that two claims would be paid on the same day for the same patient in a group practice. The MCPM citation §30.6.5 continues with the following: "Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group." However, many practices choose to present a united face to their patients and treat ophthalmologists and optometrists as though they were a single specialty.


What challenges are practices facing with code selection for office visits that they previously coded as consultations?

A: Despite the fact that consult codes are E/M codes, confidence in the E/M rules seems low. The rules are different for established patients than they are for new patients, and physicians seem confused about how to apply them. This lack of confidence will ultimately lead to claims that are either underbilled by the physician who errs on the conservative side or overbilled by the physician who does not apply the rules correctly and chooses poorly.


Are there any "new" requirements to document a consultation for commercial payers continuing to recognize them?

A: Although frequently not published and not particularly new, many commercial payers adopted Medicare's attitude that a written request for a consultative service should exist in the patient medical record. We recommend securing something in writing from the referring provider to document the request.


Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.