Medicare Fee Schedule Still Stings

Congress delayed for two months the 21.2-percent cut in Medicare payments to physicians that was supposed to take effect Jan. 1, but other elements of the Centers for Medicare & Medicaid Services (CMS) 2010 Physician Fee Schedule still affect your practice.

Congress' action in December did not prevent CMS from ending payment for consultation codes. CMS no longer pays physicians for consultations using the CPT consultation codes. The consultation codes comprise 99241-99244 for office or other outpatient consultations and 99251-99255 for inpatient consultations. To offset the change in billing for consultation codes, CMS increased the fees for most evaluation and management (E&M) codes and global billing codes.

Other changes include:

  • Decreasing relative values for some imaging codes to reflect changed assumptions about equipment utilization.
  • Changing Medicare geographic adjusters due to expiration of the geographic practice cost index floor. This change will cause payment cuts of up to 1.7 percent in most Texas payment areas.

Because all of these changes are in effect, the 2009 fee schedule applies only to claims with 2009 dates of service. The temporary 2010 fee schedule is in place until Feb. 28. Unless Congress acts before March 1, another new fee schedule will be in effect that implements the changes above and the 21.2-percent cut in the conversion factor.

So what does this mean to you? TMA's staff has developed an interactive tool to help you estimate the financial impact of the change in consult billing, and a table modified from CMS estimates the ultimate impact of the fee schedule changes by specialty, if the cut is enacted in March.

Consultation Code Q&A

TMA also developed answers to these frequently asked questions about the consultation codes:

Q. Are the commercial carriers planning to follow the CMS elimination of consultation codes?

A. At this time, none of the commercial carriers have issued guidance regarding elimination of consultation codes. You should watch for notifications of any change from the health plans in which you do business.

Q. Is there a modifier to indicate the principal physician of record for inpatient visits?

A. Yes. CMS guidance from the MLN Matters Number MM6740 [PDF] article says, "The principal physician of record will append modifier "-AI" Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient will bill only the E/M code for the complexity level performed."

Q. If the patient's primary insurance still accepts consultation codes and their secondary insurance is Medicare, how should I bill the service?

A. CMS guidance says you may bill one of two ways:

  • Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or
  • Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

March 17 Deadline

With all the concern and confusion over Medicare payment rates, the abolition of consultation codes, and numerous other issues, many physician practices are uncertain whether to participate in Medicare in 2010. March 17 is the deadline to make a decision. Signing a participation agreement means you agree to accept assignment for all covered services that you provide to Medicare patients in 2010. You have three options: 

If you choose to participate in 2010:

  •  Do nothing if you currently participate. 
  •  If you are not currently a Medicare participant, complete the agreement and mail it to TrailBlazer Health Enterprises, the Texas Medicare carrier. The change would be effective Jan. 1, 2010 

If you decide not to participate:

  •  Do nothing if you do not currently participate. 
  •  If you are currently a participant, write to each Medicare contractor to which you submit claims, advising of your termination effective Jan. 1. 

If you decide to opt out of the Medicare program:

  •  PAR physicians' opt-out affidavit must be submitted 30 days before the next calendar quarter ( i.e., Jan. 1, April 1, July 1, and Oct. 1) showing an effective date of the first date in that calendar quarter. 
  •  Non-PAR physicians may opt out at any time. 
  •  Before opting out, please refer to TrailBlazer's  Medicare Opt-Out Guidelines for Physicians/Practitioners [PDF]. 

The Participation Agreement (CMS-Form 460) is available on the CD-ROM distributed by TrailBlazer Health Enterprises and is posted on the TrailBlazer Web site. 

Return the form to:

Medicare Part B
Participation Agreement
PO Box 650544
Dallas, TX 75265-0544  

TMA can't advise you which direction to take, but it has recorded a one-hour Web seminar with detailed information about your participation options and the consequences of those choices.


TMA's Medicare Meltdown Action Center

Last Updated On

October 20, 2017

Originally Published On

March 24, 2010