Medicare stopped paying for consults on Jan. 1. This article will provide you with our recommendations on how to bill Medicare and private payers based on the changes made by Medicare and our knowledge of payer decisions at the time the article was written.
The government's definition of consults has changed many times to chip away at reimbursement. This has been unfortunate and, in the minds of government officials, unsuccessful. In the discussion of why Medicare has decided to discontinue paying for consults, Medicare delivered the ultimate insult when it blamed the confusion on physicians, when, in reality, Medicare created the problem. Had the government stuck with the original concept of a consult (the extra payment attached to it when the new program was implemented in 1992), there would have been no confusion.
Misguided reasoning aside, the discontinuance of payment for consults presents a big problem. There are some issues that have not been resolved and for which there are no good solutions. In addition, in some areas, the reimbursement for our services has been significantly reduced. In other areas, there will be administrative difficulties that will need to be overcome. We will go through each setting and give you our best advice on how to bill based on the changes.
New consult definition
First and foremost, CPT changed the definition of a consult this year, and for the better, in our opinion:
"A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem."
The new definition should alleviate the confusion created by Medicare and other payers over referral for treatment versus request for consultation.
In this hierarchy of rules, CPT is the foundation, but each payer determines its own rules. Medicare rules apply only to Medicare. Private payers will make their own decision as to how they will pay for consults.
However, other payers may choose to adopt the same rules. Therefore, we will discuss the charging of consults for Medicare and for private payers separately.
Do not charge Medicare for inpatient or outpatient consults. Instead, charge the following codes for all services previously charged as consults:
Emergency room. Use emergency department codes (99281-99285) for all visits, including emergency room visits in which the ER physician has also charged the ER codes.
Hospital inpatient visit. Use initial hospital care codes (99221-99223). The lowest-level code in this category (99221) requires at least a detailed history and physical examination. If these requirements are not met, we recommend that you use the appropriate-level subsequent hospital visit code.
Office or other outpatient visit. Use new patient codes for all patients who have not had a face-to-face visit/charge for the past 3 years. Use established patient codes for all other patients, including patients referred for a new problem.
Use Medicare rules when Medicare is the primary payer. If Medicare is the secondary payer, you can bill the private payer the appropriate consult code and then you may be able to change the code to the comparable E&M code and report the amount paid by the private payer. Medicare will then determine the additional amount that it should pay based on its fee schedule for that particular code.
Alternatively, you always have the choice of billing the private payer the appropriate Medicare acceptable code and then bill the same code to Medicare.
Private payer consults
For private payers, continue to bill all consult codes as you have in the past unless the payer specifically states otherwise.
Keep in mind that all Medicare Advantage patients (Medicare Part C, Medicare HMOs, etc.) are private payers. They are not considered Medicare patients, and you are not required to use Medicare rules for them. However, we have received word that UnitedHealthcare will follow Medicare rules on all of its Medicare Advantage plans, such as SecureHorizons, AARP, MedicareComplete, Evercare, and AmeriChoice.
We strongly recommend that you keep a close watch on payer communications and payments from all payers in order to determine the rules each payer plans to follow.
Modern Medicine NETWORK
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Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.