Medicare Update
[Note: Thank you to the Alameda-Contra Costa Medical Association for compiling the following and permitting SDCMS to reprint it here.]
21.2 Percent Medicare SGR Cut Stopped
Responding to organized medicine advocacy, President Obama signed legislation preventing the scheduled 21.2 percent cut in Medicare payments from taking place on Jan. 1, 2010. The cut is delayed for 60 days, until Feb. 28, 2010, giving Congress time to adopt a longer-term solution to the unfair Medicare payment formula known as the “Sustainable Growth Rate” (SGR). This means that the fee schedule posted on Dec. 17, 2009, by Medicare contractor Palmetto GBA — see Fee Schedules under the “Self-service Tools” list at www.palmettogba.com/J1B — is 21.2 percent lower than it will actually be on Jan. 1, 2010.
Passage of legislation to stop the 21.2 percent cut prompted Medicare to extend the 2010 “participation” enrollment deadline again, until March 17, 2010. The effective date for any participation status change during the extension, however, remains Jan. 1, 2010, and will be in force for the entire year.
Consultation Codes Eliminated and Other Codes Revalued Effective Jan. 1, 2010
Unfortunately, changes in payment policies and valuations of individual codes that were incorporated in the Medicare payment rule for 2010 remain in effect, and Medicare has refused to delay or reverse these changes. This includes elimination of payment of consultation codes and reduced valuation of many procedural codes. E&M codes will receive increases in valuation under the rule. The expected results are modest increases in average Medicare pay for physicians in primary care and reductions in average pay for some specialists. Projected changes are as follows (from highest to lowest):
- Ophthalmology +5 percent
- Family Practice +4 percent
- General Practice +3 percent
- Geriatrics +3 percent
- Internal Medicine +2 percent
- Interventional Radiology -3 percent
- Urology -4 percent
- Radiology -5 percent
- Cardiology -8 percent
- Nuclear Medicine -18 percent
SDCMS to Offer Webinar on Billing for Consultations, Making a Decision on “Participation”
SDCMS will host a webinar to assist member physicians and their office staff who might be unsure how to bill for consultations and who would also like guidance on making a decision about whether to be a “Participating” or “Non-participating” physician in Medicare in 2010. Watch your emails and faxes for a specific date and time.
Initial Guidance on Billing for Consultations (Prepared From Information Provided by the California Medical Association)
The eliminated consultation codes comprise 99241–99244 for office or other outpatient consults and 99251–99255 for inpatient consultations. According to the new rules, Medicare is requiring physicians instead of billing for consultation services to bill using evaluation and management (E&M) codes from the Office and Other Outpatient Services, Initial Hospital Care, and Initial Nursing Facility sections of the 2010 CPT coding guidelines. Physicians using electronic medical and health records (EMR/EHR) software and practice management and other coding systems should contact their vendors for any necessary program updates. Guidance on coding is as follows:
Office and Other Outpatient Services: For consultative services provided in physician offices or other outpatient settings, physicians will need to report the level of care provided based on CPT coding requirements for E&M services (i.e., history and exam, medical decision making and contributory factors presenting problem [severity], counseling, coordination of care, and typical face-to-face time). For example, instead of using criteria for consultation CPT codes 99241–99245, physicians will need to follow AMA CPT coding guidelines for CPT codes 99201–99205 and 99211–99215 to determine the appropriate level of care (new or established) provided to the patient. “The descriptors for the levels of E&M recognize seven components, six of which are used in defining the levels of E&M services. The first three components (history, examination, and medical decision making) are considered the key components and are required in selecting the appropriate level of E&M services. The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors and, while important, they are not required to be provided during each patient encounter” (source AMA CPT 2010). It is important to note that there is time variance between consultation codes and office visit codes that the physician typically spends face-to-face with the patient according to CPT coding guidelines. However, time references in CPT guidelines are only averages, and therefore coding should depend on the actual clinical circumstances. Given the change in these rules, physicians should familiarize themselves with CPT coding guidelines when 50 percent or more of the visit is spent on counseling and/or coordination of care, and the use of CPT Prolonged (Face-To-Face) Service Add-on codes (99354–99357). The following illustrates the crosswalk between outpatient consultation codes and corresponding E&M codes:
Figure 1
CPT CONSULTATION CODE: 99241
Coding Crosswalk — New Patient (requires all three key components): 99201
- Problem focused History
- A problem focused examination
- Straightforward medical decision making
CPT Crosswalk — Established Patient (requires two of three key components): 99211
- Problem focused history
- A problem focused examination
- Straightforward medical decision making
CPT CONSULTATION CODE: 99242
Coding Crosswalk — New Patient (requires all three key components): 99202
- An expanded problem focused history
- An expanded problem focused examination
- Straightforward medical decision making
CPT Crosswalk — Established Patient (requires two of three key components): 99212
- An expanded problem focused history
- An expanded problem focused examination
- Straightforward medical decision making
CPT CONSULTATION CODE: 99243
Coding Crosswalk — New Patient (requires all three key components): 99203
- A detailed history
- A detailed examination
- Medical decision making of low complexity
CPT Crosswalk — Established Patient (requires two of three key components): 99213
- A detailed history
- A detailed examination
- Medical decision making of low complexity
CPT CONSULTATION CODE: 99244
Coding Crosswalk — New Patient (requires all three key components): 99204
- A comprehensive history
- A comprehensive examination
- Medical decision making of moderate complexity
CPT Crosswalk — Established Patient (requires two of three key components): 99214
- A comprehensive history
- A comprehensive examination
- Medical decision making of moderate complexity
CPT CONSULTATION CODE: 99245
Coding Crosswalk — New Patient (requires all three key components): 99205
- A comprehensive history
- A comprehensive examination
- Medical decision making of high complexity
CPT Crosswalk — Established Patient (requires two of three key components): 99215
- A comprehensive history
- A comprehensive examination
- Medical decision making of high complexity
Inpatient and SNF Services: Physicians will no longer use CPT codes 99251–99255 for reporting consultative services provided to patients in inpatient hospital or skilled nursing facility settings. Instead, physicians (and qualified nonphysicians) are required to report these services by selecting the appropriate CPT Initial Hospital Care codes (99221–99223) or nursing facility care codes (99304–99306). There is no direct crosswalk between hospital consultation codes and initial hospital care and nursing facility codes. To crosswalk, physicians should choose the corresponding initial hospital care or nursing facility care code that meets all three levels of the key components (History & Exam, Medical Decision Making; Presenting Problem(s)). (For detailed guidance on determining the appropriate E&M code that describes the level of service provided in a consultation, refer to the E&M guidelines in the American Medical Association’s CPT 2010). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.
Modifier “-AI”: Another important change is that the modifier “-AI,” defined as “Principal Physician of Record,” must be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record must append modifier “-AI” in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E&M code for the complexity level performed.
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