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Reducing Compliance Risk- Strategies for Medicare Consultation Billing 2010 AAHAM Keystone Educational Meeting February 18, 2010. Agenda. Introductions Overview of 2010 Consultation Code Changes New Billing Guidelines Hospital/Nursing Facilities Office or Outpatient Services

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Reducing Compliance Risk-Strategies for Medicare Consultation Billing 2010AAHAM Keystone Educational MeetingFebruary 18, 2010



  • Introductions

  • Overview of 2010 Consultation Code Changes

    • New Billing Guidelines

    • Hospital/Nursing Facilities

    • Office or Outpatient Services

  • Third Party Payer Impact

  • Questions?

Consultation code changes 2010

Consultation Code Changes 2010

Effective January 1, 2010, Medicare will no longer recognize AMA CPT consultation codes (ranges 99241-99245, and 99251-99255).

Effects both inpatient facility and office or outpatient settings where consultation codes were previously billed.

CMS maintains that the change is budget neutral.

Why discontinue consultation codes

Why Discontinue Consultation Codes?

“Rationale for differential payment is no longer supported because documentation requirements are now similar across all E&M services.”

Confusion regarding use of consultation codes.

Unable to achieve sustainable improvements subsequent to education efforts.

Overview of changes

Overview of Changes

Physicians and qualified NPP’s use E&M codes to report consultations based on:

Where services take place;

Exception - Observation

Complexity of Service

Utilize the code that most appropriately supports the level of service that the Physician or NPP provided and documented.

Inpatient nursing facility consultations

Inpatient/Nursing Facility Consultations

Hospital E&M codes;

Initial hospital care codes - 99221-99223

Subsequent hospital visit codes – 99231-99233

Nursing facility care codes;

Initial nursing facility care codes - 99304-99306

Subsequent nursing facility care codes – 99307-99310

Admitting physician appends modifier “AI”

No payment differential

Identifies the physician who oversees patient’s care from the other physicians who may be furnishing specialty care

Observation service consultations

Observation Service Consultations

Evaluation of Observation patient while in Observation status;

New patient codes - 99201-99205

Established patient codes - 99211-99215

Emergency department consultations

Emergency Department Consultations

Utilize Emergency Department codes that describes the services provided in the Emergency Department;

Emergency Department Visit – 99281-99288

If patient is admitted to the hospital by consultative physician, the consultative physician should bill an initial hospital care code.

Outpatient consultations

Outpatient Consultations

Office and other Outpatient E&M codes;

Depending on complexity of patient;

New or established patient to the physician;

New patient codes - 99201-99205

Established patient codes – 99211-99215

New patient versus established patients identified by:

New patient – No professional face-to-face services by physician or practitioner of same specialty within group with 3 years.

Established patient – Professional services to patient within past 3 years;

In the office;

In the office with different diagnosis;

Other setting.

Third party payer implications

Third Party Payer Implications

Medicare is Primary or Secondary

Must use appropriate E&M code to bill Medicare.

If primary payer recognizes consultation codes, provider can;

Bill primary with applicable E&M code and submit secondary claim to Medicare;

Bill primary payer with consultation code, then report actual amount payment along with E&M code that is appropriate for the service to Medicare.

Operational strategies getting it right up front

Operational Strategies – Getting it Right Up Front

Update all fee slips/encounter forms

Update all inpatient cards

Develop educational materials to explain changes to physicians, support clinicians, coders and revenue cycle personnel.

Research major Third Party Payers consultative billing rules;

Medicare HMO products

Non-Medicare Products

Develop coding matrix for Business Office relative to Third Party Payer crosswalks

Implement edits within billing system

Cms guidance

CMS Guidance

Med Learn Matters;

MM6740 dated December 14, 2009

Additional questions

Additional Questions

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