Specialists Say Medicare Consultation Code Rule Undervalues Their Work

Texas Medicine Magazine Logo

Medical Economics Feature - March 2010  


Tex Med.  2010;106(3):25-28.  

By  Ken Ortolon
Senior Editor  

Houston neurologist William Gilmer, MD, is worried. He's afraid a recent Centers for Medicare & Medicaid Services (CMS) decision to stop paying for a set of CPT codes normally billed when specialists consult with other physicians will seriously limit Medicare patients' access to specialists. Under the change, consultations are billed using lower paying outpatient and inpatient visit codes. Dr. Gilmer says that could force him to limit the number of Medicare patients he sees.

"My practice is almost exclusively consultations," Dr. Gilmer said. "I don't admit patients to the hospital. I usually want the patient to have a primary care doctor whom I can work with. So almost everything I do is a consult or a follow-up."

Dr. Gilmer is not alone in his concern. Cardiologists, pulmonologists, endocrinologists, orthopedists, and other specialists say their practices could take a huge hit as a result of the change. They are concerned that seniors' access to specialty care also could be affected at a time when Medicare payments often don't cover the full cost of providing care.

The CMS decision caused a rift in the house of medicine because primary care physicians supported the change. They will see their reimbursement go up because the money previously earmarked for the consultation codes was shifted to codes that primary care doctors frequently bill. While specialists also bill many of those codes, the increased revenue from them may not offset the losses from the consultation codes.

Former Texas Medical Association Board of Trustees Chair C. Bruce Malone, MD, says the primary care physicians deserve the fee increase but not at the expense of specialists.

"It's totally outrageous," said Dr. Malone, an Austin orthopedic surgeon. "It's a declaration by the government that they're going to steal our services. It's not that they are not going to pay me anything, but they're going to artificially undervalue it just because they said so, not because it makes any sense."

TMA officials say the concerns go beyond access to specialty care. They see great potential for confusion and administrative hassles for physician offices, depending on whether Medicaid and commercial health plans follow Medicare's lead.



Where's the Value?  

The decision to discontinue payment for the consultation codes took effect Jan. 1 as part of the 2010 final Medicare Physician Fee Schedule rule that also included a 21-percent reduction in Medicare physician payments.

Congress postponed that cut until March but failed to address the consultation code issue. Thus, the rule took effect despite an American Medical Association effort to persuade CMS to delay implementation for at least a year to study its ramifications. CMS told AMA that it could not delay implementation of one part of the rule without delaying the entire rule. Congress, however, could delay implementation of that portion of the rule, and some specialty societies support legislation by U.S. Sen. Arlen Specter (D-Pa.) to do just that.

The new rule impacts both outpatient and inpatient consultations and CPT codes 99241 through 99245 and 99251 through 99255. Instead of billing those consultation codes, specialists now must bill the appropriate evaluation and management (E&M) code for either an initial visit or established patient visit. Also, the physician who admits the patient must append modifier "AI." This modifier distinguishes the physician who oversees the patient's care from all other physicians who furnish specialty care.

CMS made eliminating the consultation codes budget-neutral by shifting the money that would have paid for those codes into fees for some office and inpatient visits. The work relative value units (RVUs) for office visits increased by 6 percent, while RVUs for initial hospital and nursing facility visits went up 2 percent. Work RVUs are one of several components upon which CMS bases fees for physician services.

Even though those fee increases apply to the codes that specialists bill for consultations, some specialists say they will see a net decrease in their fees of up to 16 percent from what the consultation codes paid. TMA officials say fees for some inpatient visit codes may actually be higher than the low-level consultation code fees, but the overall impact of the change will be lower payments for most specialists doing consultations.

TMA staff members have developed an  interactive tool  for determining how the consultation code change might affect your practice.

CMS's rationale for discontinuing use of the consultation codes was twofold.

First, it argued that there was long-standing confusion and disagreement among physicians over what constituted a consultation as opposed to a referral or a transfer of care. This, CMS officials say, caused large numbers of consultation codes to be billed in error.

Officials at TrailBlazer Health Enterprises, the Medicare administrative contractor for Texas, Oklahoma, New Mexico, and Colorado, say that certainly was the case in this region.

Debra Patterson, MD, TrailBlazer medical director for the region, says previous comprehensive error rate testing (CERT) consistently showed consultation codes ranked high, both in terms of absolute error rates and the dollar amount of claims that were billed improperly.

"We haven't had a CERT error rate in a couple of years, but there's no reason to think that it would be any better because it was not getting any better over the two or three years that we had numbers," Dr. Patterson said.

The other reason CMS cited was that the rationale for high payments for consults was "no longer supported because documentation requirements are now similar across all E&M services," the agency stated in the new rule.

Primary care physicians agreed. In a July 29, 2009, letter supporting the new rule, American Academy of Family Physicians Board Chair Jim King, MD, said all medically necessary Medicare services require documentation in some form in the patient's medical record.

"As noted in the proposed rule, the distinction between consultations and other E/M services has become increasingly blurry over time, leading to significant misuse of the consultation codes, which the Office of Inspector General has documented," Dr. King wrote. "Thus, because it is impossible to justify the difference in physician work assigned to these services, and because this proposal offers significant reductions in administrative burden and compliance risk to physicians, we support CMS's proposal to shift the difference in RVUs to other E/M services done in the same setting."



Impact on Access  

However, specialists disagree that work requirements are essentially equivalent and that the change will reduce administrative hassles.

Dr. Malone frequently consults with emergency room physicians on how to treat patients with orthopedic injuries. Those consultations often are at night or on weekends, requiring him to leave home to go to the emergency room.

"Now I can't charge for that," he said. "I can charge only for an office visit, but this is a completely different thing than an office visit. In an office visit, I'm here, the patient's coming to me; it's maximally efficient."

Dr. Malone fears the fee reduction will prompt some orthopedists or other specialists to stop taking emergency room call for such consultations.

Dr. Gilmer points out that consultations simply take more time, training, and expertise than a routine office visit, particularly in neurology.

"Many of our patients are demented, have memory issues, don't know what's wrong with them, can't describe what's wrong with them," Dr. Gilmer said. "As a neurologist, I spend an hour or more trying to sort out a patient's problems when they can't explain it to me because it's a neurological problem, and communication is neurological."

Dr. Gilmer adds that the inpatient and outpatient visit codes do not require sending a written report to the physician who sought a consultation. Without that requirement, some specialists are concerned the reports might not get back to the requesting physician or won't be as detailed.

"That totally negates the purpose of going to a specialist," Dr. Gilmer said.

In August comments to CMS opposing elimination of the consultation codes, TMA Council on Socioeconomics Chair Skip Brown, MD, said adequately compensating specialty physicians for providing the reports benefits patient care.

At a Harris County Medical Society Board of Trustees meeting in January, some primary care physicians also expressed concern that they and their patients would lose access to specialist consultations because of the CMS decision, said Dr. Gilmer, president of the Harris CMS.



Miscoding Correctly  

Finally, TMA officials say the CMS decision likely will cause great confusion and administrative hassles because not all payers are following suit. Already, UnitedHealthcare and the Texas Medicaid program have said they will continue to pay the consultation codes. At press time, other carriers had not decided what they would do.

That means physicians' billing staff must be aware of which insurers pay the consultation codes and which don't. However, the real confusion likely will arise when there is a secondary payer involved in a Medicare claim.

In those cases, a physician's office will have to decide on one of two options. It can either file one claim for the lower paying code with Medicare and have Medicare automatically "crosswalk" that claim over to the secondary payer or file two separate claims billing Medicare for an E&M visit code and the secondary payer for the higher paying consultation code.

Dr. Patterson says the extra expense of billing two separate claims may not be worthwhile for some physicians.

She says physicians also should be aware that there used to be five levels of initial hospital inpatient consultation codes. Now they can bill only three levels of initial hospital visit codes.

"They're going to have to come up with a way to bill for those lower consult services," she said.

Dr. Patterson says physicians have two options for billing the lower level inpatient consultations when the work and medical necessity of the encounter does not reach the minimum CPT and CMS requirements of any existing initial hospital visit code.

"They can either use an NOC code - not otherwise classified - 99499, which requires them to send in the record and we have to manually review it," Dr. Patterson said. "We can price it precisely based on what's documented, but doing a manual claim like that possibly is going to slow down their claim-processing time.

"Or they can bill a subsequent hospital services code," she added. In a  Jan. 7 notice posted on TrailBlazer's Web site , the company advised physicians that they could bill subsequent hospital services codes that appropriately reflect the physician work and medical necessity for the service even though those normally would not be the correct codes.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at  Ken Ortolon .  



March 2010 Texas Medicine Contents
Texas Medicine Main Page  

Last Updated On

January 27, 2016

Related Content

Coding | Medicare