Reducing Compliance Risk-Strategies for Medicare

Consultation Billing 2010AAHAM Keystone

Educational MeetingFebruary 18, 2010

2

Agenda

• 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

• 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?

• “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

• 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

• 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

• Evaluation of Observation patient while in Observation status;– New patient codes - 99201-99205

– Established patient codes - 99211-99215

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

• 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

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

• 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

Med Learn Matters;

MM6740 dated December 14, 2009

Additional Questions