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Medicare’s Non-coverage of Consultations 2010
Effective January 1, 2010 Medicare will no longer recognize/pay for office 99241-99245 and hospital 99251-99255 consultation services. Instead, they are advising the use of new (99201-99205) or established (99212-99215) visit codes in the outpatient setting and initial hospital care codes (99221-99223) in the inpatient setting. The good news is that providers will no longer need to jump through Medicare’s documentation “hoops” to meet the often confusing consultation coding rules. The bad news is consulting practices are likely to see a drop in reimbursement from Medicare. This also means that since other payers will continue to accept consultation codes, codes will have to be maintained on charge tickets. In order to correctly charge for visits to Medicare, a coding matrix can have to be developed to crosswalk consult codes to new or established outpatient and initial hospital care codes. (See the Sample Outpatient Consultation Crosswalk Table below) This is a relatively simple process in the outpatient setting. A 99241 easily crosswalks to a new patient 99201 or an established patient 99212. The crosswalk is slightly cumbersome when converting levels 99242-99244 to established patient codes. For example, a 99242 crosswalks to either a 99212 or 99213 which require 2 of the 3 key components, History, Exam and Medical Decision Making (MDM), depending upon whether your practice requires MDM to be one of the two key components when selecting the code level (which most closely supports medical necessity). Following the same example, the consultation code 99242 requires an Expanded Problem Focused History and Exam and Straightforward MDM. A 99213 requires the same level of History and Exam but requires Low MDM. If the documentation only supports an Expanded Problem Focused History and/or Exam with Straightforward MDM you will have the choice of coding a 99212 based upon the level of MDM or a 99213 based solely upon 2 of the 3 key components. Inpatient Services The crosswalk for inpatient consultations is more problematic but in some ways straightforward. The November 25, 2009 Federal Register only mentions initial hospital care (i.e. admission) codes as an alternative to inpatient consultations. A request for consultation must be crosswalked to the initial care codes only, or per coding guidelines, an unlisted evaluation and management code. (See Inpatient Consultation Crosswalk Table below) Because of statute, Medicare will cover telehealth consultation services (G0406-G0408), but remember these are the only consultation services allowed. As you can see in the crosswalk table, 99251 and 99252 have no corresponding admission codes, so if these levels are documented the codes will have to be crosswalked to the unlisted code 99499, which will require the submission of visit notes to Medicare for adjudication. The other inpatient consultation codes, 99253-99255 easily crosswalk to the admission codes 99221-99223. Admitting/attending physician Consulting physicians will have to change how and what gets coded to Medicare in this setting. The new rules require the admitting physician to append the new HCPCS modifier “AI”, (Principal physician of record), to the initial hospital care code. The expectation is that the use of this modifier will allow two initial visit codes to be reported on the same date of service. What’s Next? Since this is ultimately a payer issue, physicians/NPPs may consider reporting their services as consultations; and the crosswalk of consultation to new, established or inpatient visits be performed by the coding and billing staff following your crosswalk guidelines as defined in your compliance plan. NOTE: The reader should note that this article presents only partial summaries of complex and detailed provisions. It is provided for informational purposes only and should not be relied upon for legal, medical or financial advice. As with all aspects of the healthcare industry today, things are subject to change. BNN is pleased to continue to serve our clients, and happy to provide this important industry information to the community. For more information we encourage you to contact Laurie Desjardins, Senior Manager on the Revenue Management Team in BNN’s Healthcare Management Division at ldesjardins@bnncpa.com or 207.791.7149, or contact your BNN Healthcare Consultant or other professional at 800.244.7444.
Consultation Crosswalks
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