2010 Changes – Physician Fee Schedule Billing & Reimbursement for ConsultationsDecember 16, 2009

Elimination (Medicare) of Consultation Codes

• Published on November 25, 2009 – Federal Register, Volume 74, No. 226, starting on page 61769, final rule, effective January 1, 2010 discusses rationale for elimination of inpatient and outpatient consultation codes

• Effective January 1, 2010, the following codes will no longer be accepted by Medicare:

• 99241-99245 (Outpatient consultations)• 99251-99255 (Inpatient consultations)

• However, effective January 1, 2020, HCPCS codes for provision of inpatient consultations by telehealth have been created to provide practitioners the ablility to provide and bill initial inpatient

consultations when furnishing services that meet Medicare requirements relating to coverage and payment for telehealth services

New HCPCS Codes for Initial Inpatient Consultations provided via Telehealth

Effective January 1, 2010, the following HCPCS codes are approved for Telehealth:

•G0425 – initial inpatient telehealth consultation, typically 30 minute communicating with the patient via telehealth

•G0426 – initial inpatient telehealth consultation, typically 50 minutes communicating with the patient via telehealth

•G0427 – initial inpatient telehealth consultation, typically 70 minutes communicating with the patient via telehealth

What do Physicians and NPs Bill Instead of Consultation Codes?

• Physicians and NPs 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

(CPT codes 99221-99223 & 99304-99306)

• Subsequent care visits by physicians and NPs will be reported as subsequent hospital care codes and subsequent nursing facility codes

(CPT codes 99231-99233 & 99307-99310)

Reimbursement/RVU Implications

•Changes are being made in a budget neutral manner

•Physician work RVU’s for new and established office visits are being increased by approximately 6% to reflect the elimination of the outpatient consultation codes

•Physician work RVU’s for initial hospital and facility visits are being increased by approximately 2% to reflect the elimination of the facility consultation codes

Commentator Concerns

•Some commentators on the proposed changes urged that they not be finalized for January 1, 2010 because of concerns whether there would be sufficient time to educate providers about the changes

•Committee agreed that adoption of these changes require measures to appropriately educate physicians and billing personnel about the change, but the committee did not believe that the requisite educational efforts are extensive and complex enough as to warrant delaying implementation of the proposal; therefore – for Medicare, Consultation codes are no longer valid effective 1/1/10!!

Commentator Concerns

•Some commentators expressed concern about the effects of this proposal on coordination of payment between CMS and other payers; there was concern that if other payers continue to recognize consultation codes there would be confusion, erroneous billings and payment denials

•Committee responded that in cases where other payers do not adopt this policy to eliminate consultation codes, physicians and their billing personnel need to recognize that Medicare will no longer accept consultation codes whether for primary or secondary payment

Commentator Concerns

• If a payer other than Medicare is primary and continues to recognize consultation codes, the physician will need to decide whether to bill the primary payer using visit codes, which will preserve the possibility of receiving a secondary Medicare payment, or to bill the primary payer with the consultation codes, which will result in a denial of payment for invalid codes

Medicare Status Code Indicators

Medicare Status Code Indicators

•All consultation codes have been given a status indicator of “I”

Physician Work RVU Comparison for E&M codes – 2009

Physician Work RVU Comparison for E&M codes – 2010

2009 vs. 2010 Physican Work RVUs

2009 Physician Work RVU 2010 Physician Work RVU

• Make sure to work with your billing department and revenue cycle staff to determine billing and chargemaster implications for the elimination by Medicare of consultation codes

• Make sure that your contracting department is discussing other payer policies around acceptance vs. non-acceptance of consultation codes

Communicate with your Finance Department Team Members About the Changes