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Savvy Coder: Coding & Reimbursement
CMS Scraps the Consultation Codes, Part Two: The Financial Impact on Your Practice
By Sue Vicchrilli, COT, OCS, Academy Coding Executive and Stephen A. Kamenetzky, MD, OCS, Chairman of the Ophthalmic Coding Module Series
 
 

(PDF 325 KB)

Since Jan. 1, Medicare has eliminated use of the consultation codes in the office and inpatient hospital settings. The financial implications of this are mixed.

First, the bad news. Medicare paid more for the scrapped codes than they do for the codes you are now expected to use. Last year, for instance, you would typically have been paid $92 for CPT code 99242 Office consultation, whereas this year you will typically receive $70 if you use E&M code 99202 Office or other outpatient visit.

So what’s the good news? To compensate for the loss of the relatively well-paid consultation codes, CMS has beefed up the “work Relative Value Units” associated with payments for certain other codes, such as the codes for new and established office visits. For instance, the typical Medicare rate for E&M code 99202 rose from $64 to $70. (There also were smaller increases in the work RVUs for initial hospital and facility visits.) To get a rough idea of how this impacts you, create a spreadsheet, like in the two examples.

BELOW, EXAMPLE 1: COMPREHENSIVE OPHTHALMOLOGIST'S SPREADSHEET.
This doctor sees patients four days a week in one office location, with one surgical day a week. (Reporting period is January to March 2009.)
Total 2009 revenue: $128,489
Total 2010 revenue: $136,685
Difference: $8,196 additional revenue

Exam
Code
Description No. of
Medicare
Patients
2009 Typical
Allowable
2009
Payment
2010
Typical
Allowable
2010
Payment
92002 Eye code: New patient, intermediate   18 $   68 $   1,224 $   73 $   1,314
92004 Eye code: New patient, comprehensive 132 $ 127 $ 16,764 $ 137 $ 18,084
92012 Eye code: Established, intermediate 117 $   71 $   8,307 $   78 $   9,126
92014 Eye code: Established, comprehensive 629 $ 104 $ 65,416 $ 113 $ 71,077
99201 E&M: New patient, office visit, level 1     8 $   37 $      296 $   40 $      320
99202 E&M: New patient, office visit, level 2   10 $   64 $      640 $   70 $      700
99203 E&M: New patient, office visit, level 3   27 $   93 $   2,511 $ 101 $   2,727
99204 E&M: New patient, office visit, level 4   16 $ 143 $   2,288 $ 156 $   2,496
99205 E&M: New patient, office visit, level 5     1 $ 181 $      181 $ 196 $      196
99211 E&M: Established, office visit, level 1     1 $   19 $        19 $   20 $        20
99212 E&M: Established, office visit, level 2   20 $   37 $      740 $   40 $      800
99213 E&M: Established, office visit, level 3 202 $   62 $ 12,524 $   68 $ 13,736
99214 E&M: Established, office visit, level 4   67 $   93 $   6,231 $ 102 $   6,834
99215 E&M: Established, office visit, level 5     9 $ 126 $   1,134 $ 137 $   1,233
99242 E&M: Consultation, office, level 2   46 $   92 $   4,232 $   70 $   3,220
          (Now 99202)
99243 E&M: Consultation, office, level 3   46 $ 126 $   5,796 $ 101 $   4,646
          (Now 99203)
99244 E&M: Consultation, office, level 4     1 $ 186 $      186 $ 156 $      156
          (Now 99204)

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Exam
Code
Description No. of
Medicare
Patients
2009 Typical
Allowable
2009
Payment
2010
Typical
Allowable
2010
Payment
92004 Eye code: New patient, comprehensive     8 $ 127 $   1,016 $ 137 $   1,096
92012 Eye code: Established, intermediate   17 $   71 $   1,207 $   78 $   1,326
92014 Eye code: Established, comprehensive 490 $ 104 $ 50,960 $ 113 $ 55,370
99204 E&M: New patient, office visit, level 4   42 $ 143 $   6,006 $ 156 $   6,552
99205 E&M: New patient, office visit, level 5     1 $ 181 $      181 $ 196 $      196
99214 E&M: Established, office visit, level 4     8 $   93 $      744 $ 102 $      816
99215 E&M: Established, office visit, level 5   52 $ 126 $   6,552 $ 137 $   7,124
99243 E&M: Consultation, office, level 3     1 $ 126 $      126 $ 101 $      101
          (Now 99203)
99244 E&M: Consultation, office, level 4   86 $ 186 $ 15,996 $ 156 $ 13,416
          (Now 99204)
99245 E&M: Consultation, office, level 5     1 $ 229 $      229 $ 196 $      196
          (Now 99205)

ABOVE, EXAMPLE 2: RETINA SPREADSHEET.
This doctor sees patients two-and-a-half days a week in three office locations, with two surgical days a week. (Reporting period is September to November 2009.)
Total 2009 revenue: $83,017
Total 2010 revenue: $86,193
Difference: $3,176 additional revenue

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You should keep in mind that CMS also increased the reimbursement rates for all surgical procedures that have a postop period.

To complicate matters, your non-Medicare payers won’t necessarily follow CMS—some may continue to accept consultation codes.

In conclusion, for most Eye M.D.s with “standard” practices, the AAOE’s initial estimates suggest that these changes will be close to revenue neutral.

Please note. In the two examples, the 2010 projections assume that Medicare cuts associated with the sustainable growth rate formula are not implemented. For news on this, visit www.aao.org/advocacy.

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