Coding & Reimbursement

What's New in Consultation Code Coverage

By Suzanne L. Corcoran, COE

Medicare continues to change reimbursement rules, presenting challenges to ophthalmic practices. In 2010, coverage for consultation codes has been eliminated. Here's a sample of some of the many need-to-know questions we are receiving.

Q. What changes were made to the payment policy for consultations?

A. The 2010 Medicare Physician Fee Schedule final rule (CMS-1413-FC) eliminates the use of consultation codes for outpatient (9924x) and inpatient (9925x) services. Transmittal 1875, published 12/14/09, provides specific instructions.

Q. How will this change affect Medicare payments?

A. CMS reports in MLN Matters issue MM6740 that the change will not increase or decrease Medicare collective payments; it is budget neutral. Nevertheless, specialists will see a significant reduction in their Medicare payments while generalists will see a small increase. CMS increased the work relative value units for office visit codes (new and established) and for initial facility visits (hospital and nursing facility) and considered the increased use of these services in the final calculation of practice expense and malpractice expense.

Q. What CPT codes replace the consultation codes?

A. Visits previously coded as outpatient consultations will be coded with the appropriate evaluation and management code (992xx) based on the amount of history, exam and decision making. Ophthalmologists and optometrists may also utilize the eye codes (920xx) if the visit satisfies their criteria.

Inpatient services previously coded with 9925x will be replaced with initial hospital care codes 99221 through 99223 or nursing facility care visit codes 99304 through 99306. This instruction poses a technical challenge since the admitting physician and the consultant must both use the same CPT code set, which is counterintuitive. CMS created modifier “AI” to address this. The admitting or attending physician will use this new modifier while the consultant will not.

You may also use the eye codes when they best describe the service. The place of service on the claim must match the location where the service was rendered. For inpatient exams, the site of service reduction applies.

Q. Is there a code “crosswalk” from outpatient consultation codes to E/M codes?

A. The selection of an E/M code is based on the E/M guidelines that define the history, exam and decision making. Alternately, eye codes apply when the documentation supports their use.

• 99241 = 99201 or 92002
• 99242 = 99202 or 92002
• 99243 = 99203 or 92004
• 99244 = 99204
• 99245 = 99205

Because the E/M definitions are more lenient for established patients, the crosswalk is more complex.

Possible eye code choices are provided for consideration:

• 99241 = 99212 or 92012
• 99242 = 99213 or 92012
• 99243 = 99214 or 92014
• 99244 = 99215
• 99245 = 99215

Q. Is there a code “crosswalk” from the inpatient consultation codes to the E/M codes?

A. It's challenging, because there are only three CPT codes for initial facility care whereas there were five levels of inpatient consultation codes. The history and exam for 99251 and 99252 are too abbreviated to crosswalk to an E/M code.

Possible choices are:

• 99251 = 92002 / 92012
• 99252 = 92002 / 92012
• 99253 = 99221, 99304, 92004 or 92014
• 99254 = 99222 or 99305
• 99255 = 99223 or 99306

Q. Is a written report back to the referring provider still required?

A. No, but CMS recommends it to support coordination of care among physicians. Many physicians will continue to send correspondence for public relations reasons as well.

Q. Will commercial payers and Medicare Advantage (MA) plans continue to recognize consultation codes?

A. Many commercial payers and MA plans may choose to follow Medicare's lead. Watch payer Web sites and newsletters for any changes.

Q. Will commercial payers and MA plans continue to recognize consultation codes? What about Medicare secondary payer (MSP) claims?

A. Many commercial payers and MA plans may choose to follow Medicare's lead; watch payer Web sites and newsletters for any policy changes.

MSP claims may be paid by the primary insurance, but Medicare still will not recognize consultation codes, even as secondary payer. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.