(PDF 63.2 KB)
Consultation or transfer of care? Despite Medicare’s attempts to clarify matters, confusion over when to use the consultation codes has been a common cause of denied claims. According to CMS, both Focused Medical Review (FMR) audits and Comprehensive Error Rate Testing (CERT) audits demonstrated that physicians continued to code for a consult in circumstances that the payer determined to be a transfer of care. CMS decided that its solution would be to eliminate—as of Jan. 1—consultation codes in the office and inpatient hospital setting. This month, EyeNet explains what this means for your coding; next month, what it means for your balance sheet.
Which codes did CMS scrap? You can no longer bill Medicare for the office codes 99241, 99242, 99243, 99244 and 99245 or for the inpatient codes 99251, 99252, 99253, 99254 and 99255.
Who no longer accepts these codes? This ruling is specific to CMS and Medicare. At time of press, it was not clear how private payers, including Medicare Advantage Plans, would respond to the ruling.
How to Bill for Consults
What should you use in place of the 10 eliminated codes?
How to bill for outpatient consultations. If the patient is new to the practice, use E&M codes 99201, 99202, 99203, 99204 and 99205. If the patient is established (one who has seen a physician of the practice within the past three years), then use E&M codes 99211, 99212, 99213, 99214 and 99215. Ophthalmologists may also choose any of the Eye codes 92002, 92004, 92012 and 92014, as well.
How to bill for inpatient consultations. Physicians who perform an initial inpatient evaluation should use the initial hospital care codes 99221, 99222 and 99223. For nursing facility care, E&M codes 99304, 99305 and 99306 should be used. As a result, multiple billings in initial hospital and nursing home visits could occur even in a single day. To distinguish between the consulting physician and principal physician, CMS directs principal physicians to append modifier –AI to the appropriate level of E&M code. Consulting physicians should only submit the appropriate level of E&M code without a modifier. For subsequent inpatient care, codes 99231, 99232 and 99233 remain in effect.
Questions and Answers
Q. “If the physician writes a letter to another physician, is there a way to get paid separately for producing the letter?”
A. It will be part of the E&M or Eye code billed. No separate bill to the payer or the patient is appropriate.
Q. “Now that we can’t bill Medicare for consultations, we must use Eye codes or E&M codes. One of our optometrists refers a patient to one of our ophthalmologists with specialty training. If the visit qualifies as a comprehensive exam, would you use 92004 or 92014? The patient is not new to the practice but is new to the specialist.”
A. Either 92014 or the appropriate level of E&M code. The patient is considered to be an established patient of the practice.
Q. “If CMS eliminated consultation codes, why is the information still in CPT?”
A. The AMA CPT codebook for 2010 was published long before the Federal Register announced the elimination of consultation codes. Also, non-Medicare payers may still recognize this set of codes.
Q. “This change is said to be ‘budget neutral’ for CMS, but reimbursement for the eliminated codes was relatively unparsimonious. Where did the consultation dollars go?”
A. CMS increased the work relative value units (RVUs) for new and established E&M office visits, as well as for initial hospital and initial nursing facility visits. Work RVUs of the postop visits of surgical codes also received an increase. What does this reallocation of the consultation dollars mean for ophthalmology? Next month’s EyeNet will help you estimate what the implications will be for your practice.