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
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.
“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.
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.
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
Evaluation of Observation patient while in Observation status;
New patient codes - 99201-99205
Established patient codes - 99211-99215
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.
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;
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.
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
Develop coding matrix for Business Office relative to Third Party Payer crosswalks
Implement edits within billing system
Med Learn Matters;
MM6740 dated December 14, 2009