Ask 3 Questions to Head Off 2010 Consult Problems Before They Start

Ever used an unlisted E/M code? Get ready.

By now, you’ve heard that CMS is doing away with all inpatient (99251-99255) and outpatient (99241- 99245) consultation codes in 2010 — but are you prepared for the issues this may cause, starting Jan. 1? Ask these three questions of your practice and payers, and you’ll fend off headaches before they start.

Keep in mind: While Medicare has released the transmittal letter to all carriers instructing them about the policy change to no longer payer for consultations, Senator Arlen Specter (D-PA) introduced an amendment to the Patient Protection and Affordable Care Act (H.R. 3590) to delay this policy change by one year. This amendment was added on Dec. 14, 2009.  If Congress does not pass this bill before the end of the year, the Medicare policy will go in as planned.  Check the Ob-gyn Coding Alert and SuperCoder for more developments, but be prepared just in case.

1. Do Medicaid and Private Payers Have Consult Advice?

If a physician sends a Medicare patient to your ob-gyn for a consultation, you should use regular E/M codes (99201-99215, Office of other outpatient visit for a new or established patient …) instead. But what about the other insurers?

“We have to remember that right now, this is just Medicare,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis., who led the “Consultations” session at the 2009 Ob-Gyn Coding & Reimbursement Conference in Orlando.

Medicaid and private payers may follow suit — or they may not have even learned of CMS’s decision. “Four weeks ago, I asked a secondary insurance company what they were doing about the consultation issue, and their response was, ‘Huh?’” laments Rasmussen.

2. What Happens If Admitting Physician Forgoes Mod AI?

Admitting physicians now have a new modifier to start appending for their initial inpatient service. As soon as Jan. 1 hits, they must append modifier AI (Principal physician of record) to the initial visit code. This will denote the admitting physician is the physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875.

Translation: An emergency room (ER) doctor sees a patient who was involved in a motor vehicle accident. He calls in a trauma surgeon because of possible intra-abdominal damage, and the trauma surgeon admits the patient because of possible bleeding. The patient is pregnant, so the ob-gyn comes in for a consultation also. Trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The ob-gyn then bills 99221-99223 with no modifier.

Problem area: If the admitting physician does not include modifier AI, then the payer is receiving two initial hospital care claims for the same patient on the same day. CMS Transmittal 1875 acknowledges, “As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.” What is not clear is what to do when the admitting physician makes the mistake and your ob-gyn has submitted the claim correctly. “At this point, we’re not sure if this will cause a concurrent care issue,” Rasmussen says.

Here’s another concern. Suppose your ob-gyn does a consultation in an observation setting. Your ob-gyn will have to use an outpatient office code, but the new guidelines do not include observation codes (99217-99220) as requiring modifier AI identifying the admitting physician. Again, will this cause a concurrent care issue? If so, you better be prepared to fight for your claim.

On top of that, will your private payers even accept modifier AI if they are the secondary payer? This remains to be seen.

3. What About Hospital Inpatient Levels?

Instead of consultation codes, CMS directs you to use initial hospital care codes (99221-99223), but you have a problem. Consultation codes have five levels whereas initial hospital care codes have only three.

Requirements: Part of the rationale behind deleting consultation codes is that physicians were not meeting the level of service requirements. “When two of the three initial hospital care codes require nothing less than a comprehensive history and comprehensive exam, I’m not sure how the deletion of the consultation codes will correct these kinds of errors,” Rasmussen says.

Did you know the lowest initial hospital care code (99221) requires a detailed history and detailed exam? Most physicians “don’t get there,” Rasmussen says. In order to reach a detailed history, your physician must document an expanded HPI, review of 2-9 systems, and pertinent past, social or family history. While this level of history is not difficult to document, the physician must document a detailed exam. In support of that level of exam, you must have an evidence of an extended exam of the affected system plus 2-7 related organ systems or body areas if using the 1995 guidelines.

If you’re using the 1997 guidelines, your physician must document 2 bulleted elements from 6 systems or at least 12 bulleted elements from the GU single system exam. Many physicians don’t do this level of examination at the time of the inpatient consultation. because it may not be medically indicated.

When you don’t get to even this level (and you would’ve qualified for a level one or two initial hospital care code, if it existed), your only option is to report 99499 (Unlisted evaluation and management service). “The problem with this is that this claim will automatically go into review,” Rasmussen says. “This year’s CPT Symposium Board had no solution but realized they needed to address this.”

Be Pro-Active and Take Action to Find Answers

Even though Jan. 1 will have come and gone by publication date, you need to know the solutions to these issues. “Watch carrier bulletins,” recommends Rasmussen. Find someone who can clarify, in writing, how they want these services reported. “Harass them for answers!”

Note: Check back with the Ob-gyn Coding Alert for more minefields in the transition from consultation to E/M codes.

To obtain a CD of this year’s Ob-Gyn Coding & Reimbursement conference, go here or call 1-866-251-3060.

To view the video, click the link below

Ask 3 Questions to Head Off 2010 Consult Problems

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