Medicare 2010 CPT Consultation Code Changes

November 12, 2009

New rules for consult coding straight from the AMA Meeting in Chicago — plus where your practice will gain and lose reimbursement.

If you can’t figure out how to match a low level consult to an initial hospital care code, you’re not alone.

Code 99251 doesn’t crosswalk to 99221, agreed William J. Mangold, Jr., MD, JD, Noridian Administrative Services’ (Arizona, Montana, Utah, Wyoming) Medicare contractor medical director in the carrier response section to Day 2’s opening session at the CPT and RBRVS 2010 Annual Symposium in Chicago. “They don’t have the same criteria.”

Medicare will consider the consult codes (99241-99255) invalid codes for payment, effective Jan. 1. Experts expect some large carriers, including Blue Cross Blue Shield, Aetna, and Humana to adopt the same policy for uniformity. For carriers and private payers that no longer recognize consult codes, let these examples help you decide what code to instead use.

1. Apply Patient Status Rules to Outpatient Encounters

“CMS is saying the consult codes are going away,” Mangold explains. Instead, you should choose the appropriate code based on the applicable guidelines.

Example: An internist asks for a cardiologist’s opinion on a patient’s hypertension. The cardiologist saw the patient two years ago. There’s no documentation in the internist’s chart to confirm the request for opinion. How would you code the service per Medicare 2010 guidelines?

Answer: You would waive the referral requirement since standard coding rules apply, Mangold says. The physician has treated the patient within the past three years, so you would apply new/established patient definitions, and assign an established patient office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …).

2. Focus on Split/Shared Visits’ Total Work

You can ignore one requirement of a shared/split inpatient visit thanks to Medicare’s invalidation of the consult codes. Even if the physician does not duplicate the key components that the nonphysician practitioner (NPP) performed, you can count all medically necessary history, examination, and medical decision making that the and physician each individual performs and documents on a calendar day.

Example: An NPP shares a consult with an MD who does not perform the key components. With the existing guideline, you could not code the service as a consult. The encounters do not meet a shared/split consult’s requirement that the physician perform and document the key components.

Answer: Since there’s not a consult option using the new guidelines, the shared service would be allowed, Mangold says. Report the encounter with the appropriate hospital care code. “This is good news,” one conference attendee raved.

3. Look at Time When Choosing Inpatient Code

At the higher levels, consults’ transfer to hospital care codes will benefit your practice’s bottom line. For 99244 and 99245, you would gain approximately 30 percent in pay if you also report the prolonged services, said Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair in his “Evaluation and Management” presentation at the AMA symposium.

“The lower level reimbursement impact will mostly be negative,” Hollmann related. At the low consult levels, the hospital care codes do not match up well.

Example: On a patient’s initial day in the hospital, a nonattending physician performs only a medically necessary problem focused history and problem focused examination. This would not support 99221’s requirements of a detailed history and detailed exam, points out Joan Gilhooly, PCS, CPC, CHCC, Vice President, Audit Services and Compliance for Health Management Resources, Inc. in Salisbury, N.C.

Look to the hospital care code that appropriately describes the service, stresses Mangold. The Medicare Instructions need to be clarified on what to do when low level consult allowances don’t support 99221 or 99231.

Consider using time to line up the services , suggests Hollmann. The following possible match ups are “strictly from a CPT crosswalk – not official from CMS” (Do not use them to code exactly but as a guide).