Medicare’s Consult Rule Trickle Down Effect

And what it means for pediatric practices. A report from AMA in Chicago.

Although CPT clarifies the transfer of care definition, the fix came too late for Medicare, meaning your private payers may follow suit.

Continued Errors Result in E/M Boon

The Office of Inspector General found a high error rate on consultation codes. Different opinions on when a transfer of care occurs versus a consultation caused $1.1 billion in incorrect payments. “We couldn’t even all agree on some scenarios,” admitted 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.

Pediatricians who don’t regularly code consults could gain from Medicare getting fed up with the inconsistency and invalidating the codes for payment in 2010. CPT still maintains the codes. CMS, however, will take the payments for 99241-99255 (Consultations) and redistribute them to office visits (99201-99215), hospital care (99221-99233), and nursing home (99304-99310) codes. This will create a 6 percent boost for primary care in E/M reimbursement from private payers that adopt the 2010 Medicare Physician Fee Schedule.

Get ready for ‘Dante’s Inferno,’ says one veteran coder.

You’ll Have to Track 2 Rules

The differing rules, however, spell trouble. “We are going into Dante’s Inferno for 2010,” says
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions and Senior Coder and Auditor for The Coding Network. “We will have to manage who does and who does not allow consultation codes.” Each payer may decide at will to reject or to accept 99241-99255.

Example: A teacher requests a pediatrician’s opinion on a child with behavior issues. The physician evaluates the child and reports his findings to the teacher. According to CPT, the pediatrician could report a consult code since the encounter involves a request for opinion, rendering of exam, and repot of findings. If, however, the payer chooses to follow Medicare’s lead and not recognize the consult codes, you would instead report an office visit code (99201-99215, Office or other outpatient service …).

Since the history, examination, and medical decision making components do not match up for office visits and consults, the code level would change depending on the reporting method. This opens a can of worms. Auditors will have to figure out which service the documentation supports.

Check Out What Insurers Are Doing

Some large payers and perhaps also small payers that do not base their fee schedules on Medicare’s may not follow Medicare’s lead. Until mid-December, directives will remain unsettled. Medicare seems determined to carry out the transition, but the entity previously has reversed course (based on congressional action).

At the AMA CPT and RBRVS 2010 Annual Symposium in Chicago, a medical director indicated that at least one payer will continue to use consult codes. “Blue Cross Blue Shield of Rhode Island will accept either method,” said Peter A. Hollmann, MD, the AMA CPT Editorial Panel, Vice Chair in his “Evaluation and Management” presentation at the AMA symposium. “I’m not sure how helpful our decision will be for you considering how big a state Rhode Island is,” Hollmann joked with attendees.

BCBS RI made this decision for two reasons:

1. “We wanted to allow physicians to report based on both CMS and CPT rules,” Hollmann explains.
2. The contractor is not using the 2010 fee schedule because it can’t implement the changes by Jan. 1, Hollmann reported. “Since we’re not redistributing the relative value units” to pay office visits and hospital care services more in exchange for invalidating consult codes, “we won’t change our consult policy.”

Query Your State Program for Its Rules

Medicaid falls under CMS. Does that mean Medicaid will stop accepting consult codes as of Jan. 1?

The answer “depends on the Medicaid program in your state,” responded Kenneth B. Simon, MD, MBA, CMS senior medical officer, in the Q&A portion of “Medicare Physician Payment Schedule 2010 Changes and Beyond” at the symposium. “You’ll have to wait for instructions in your state.”

Here are two possible outcomes for one attendee’s scenario. “As a neonatalogist, I’m asked for a newborn consult, but I’m not the primary care giver. Will I be able to report a consult?”

“In general, we instructed contractors in this kind of situation that the appropriate code is a hospital care code,” Simon answered. Use an initial hospital care code (99221-99223) for an initial consult on an inpatient or a subsequent care code (99231-99233) for a follow-up consult. There’s not currently a universal Medicaid plan, he pointed out.

For a Medicaid program that sticks by CPT, the neonatalogist could code the encounter with 99251-99255 provided documentation supports the service’s definition.

From Pediatric Coding Alert. Get your 2 FREE sample issues here.

Prep staff for CPT 2010 changes in an hour with this audio from Jennifer Godreau, BA, CPC, CPEDC.

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