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Billing For Consults After “The Apocalypse”

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

“Orchestral music rises as the first glimmers of an ominous sunrise brings light to a dusty and desolate landscape, where once-plentiful streams of revenue have been vaporized by statute. Small bits of paper with numbers such as “99254″ and “99241″ blow across the feet of our stethoscope-clad hero, as he faces a future full of financial uncertainty and unwanted adventure…”.

We are now two weeks into a world where Medicare has eliminated reimbursement for inpatient and outpatient consultation codes. To many specialists for whom consultations have become a way of life, it is tempting to see themselves as a manufactured post-apocalyptic film character similar to the one above. It is my duty, as a compliance officer, certified coder and budding writer of screenplays to inform you that it doesn’t have to be that way.

In a previous post on this blog, I demonstrated one way to navigate the imperfect crosswalk that exists between inpatient consultations and the CPT codes for initial inpatient encounters (99221 through 99223) that are now to be used in its place. In the past weeks, the Medicare administrative carriers have released their own guidance about what should be billed in place of a consultation code if the documentation does not meet the requirements of CPT code 99221.

For Palmetto GBA, First Coast and WPS, the suggestion is that CPT code 99499 (Unlisted evaluation and management service) be utilized for services formerly billed as 99251 or 99252. When using this code, be aware that it lacks a set payment. The reimbursement of this code is driven on a case-by-case basis and is determined by carrier review of documentation for the service. When billing 99499 to a carrier that accepts it, always be certain to include the documentation for the service.

National Government Services, as well as other carriers, is suggesting that the appropriate inpatient follow-up code (99231 through 99233) be billed in place of a low-level consultation. The choice of code would depend on the depth of the documentation for the service.

The second challenge that has been brought forth is the question of consultations when Medicare is the secondary payer (MSP). In the final revision of the new consultation policy in MedLearn Matters article MM6740,  there are two solutions that can be used. You can either choose not to bill consultations at all to a commercial payer and be reimbursed for E/M services by both commercial and MSP, or you can bill the consultation to the commercial payer, then report the amount paid and bill an equivalent E/M code to Medicare to determine whether additional reimbursement is due.

The first solution is the path of least resistance, as this eliminates consultation billing from your practice immediately and entirely. Financially, this may not be the most advantageous approach. While commercial payers are expected to eventually follow CMS’ lead and eliminate reimbursement for consultations, these codes are still active with commercial payers at reimbursement rates that are typically larger than equivalent E/M codes based on documentation.  Contractually, if you are still receiving healthy reimbursements from commercial payers for consultations, the second approach may be more to your advantage.

The reimbursement landscape has changed, but it has not been irrevocably altered for the worse. The road to reimbursement commensurate with services performed now has a few more detours than it did a month ago, but water recedes and bridges can be rebuilt. With increased attention to documentation detail and increased awareness of the new rules of the road, providers can successfully navigate a world without consultation reimbursement.

Paul Spencer CPC, CPC-H

One Response to “Billing For Consults After “The Apocalypse””

  1. Lisa Velasquez says:

    Ha Ha, That opening paragraph gives a great visual! Especially the last line about our “stethoscope-hero”
    (love it)

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