This was emailed to be from my my main hospital as a FYI piece this afternoon:

The final physician payment rule for calendar year 2010, included in the November 25 Federal Register, addressed the new Medicare payment policy on consultation services. A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient's problem(s). It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified non-physician practitioner (NPP) at the request of another physician or appropriate source. A consultation service must be documented and a written report given to the requesting professional. The request for the consultation service must be documented in the requesting physician's plan of care in the medical record as a condition for Medicare payment.

Effective January 1, 2010, Medicare will eliminate the use of all consultation codes - inpatient and office/outpatient codes for various places of service except telehealth consultation G-codes. To retain budget neutrality, the work relative value units (RVUs) will be increased for new and established office visits and initial hospital and initial nursing facility visits. New codes have also been developed specific to the telehealth delivery of initial inpatient consultations. 
For consultation services other than those provided through telehealth, physicians are to bill an initial hospital care or initial nursing facility care code for their first visit during a patient's admission to the hospital or nursing facility in lieu of the consultation codes these physicians may have previously reported. The determination of the appropriate visit code should be made solely on the basis of the existing rules and guidelines for the use of the codes, without any reference to the guidelines that have been employed for the use of the consultation codes.

Medicare will create a modifier to identify the admitting physician of record for hospital inpatient and nursing facility admissions. The admitting physician of record will be required to append the specific modifier to the initial hospital care or initial nursing facility care code in order to be identified as the admitting physician of record who is overseeing the patient's care.

It should be noted, however, that the consultation codes are not being eliminated - they will just be no longer billable to Medicare. The codes could continue to be recognized and paid by other third party payers. Medicare will no longer recognize consultation codes submitted on bills, whether those bills are for primary or secondary payment. Physicians and their billing staff will need to identify whether other payers will continue to accept the consultation codes and respond accordingly. Particular attention will be required if claims are expected to cross between Medicare and another payer, either with Medicare as the primary or secondary payer.

Florida Hospital Association Compliance Alert

 

This is one of those "death by 1,000 paper cuts" things that CMS will do to cut back on our reimbursement insidiously. I am going to quote Mr. David Walker's blog. He is the CEO of Intellicure, wound care-oriented EMR company. According to him, in Texas, these consultation codes (being eliminated) pays 29-55% more than the new patient codes. He mentioned that, his local physician group with 4 doctors is facing a projected loss of $87,000 this year, because of this loss of consultation codes.

I am afraid that this change has been done already, and I wouldn't be surprised if the other payers follow suit. 

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From "David on Wound Care" blog,

I suppose I can take down my article about ‘Did I Document a Consult?’ from the Intellicure members website.  You may not have noticed, what with healthcare reform, proposed Medicare cuts, "meaningful use," and the Red Flag Rule all taking center stage for the past six months, but Medicare made a recent decision to eliminate consultation codes.  Frankly, this decision may have a greater affect on your practice than any of these other issues.

This decision isn’t part of the HOPPS Final Rule which we’ve been discussing, but CMS' October 30 decision to eliminate outpatient and inpatient consultation codes, effective January 1, which will affect all medical practices, including the physicians who practice in your outpatient wound care center.  These plans are budget-neutral to the Medicare program as a whole, however they have the potential of crushing the bottom line of many practices.

Across the Intellicure Wound Registry, participating physicians code 10-15 percent of their new outpatients and more than 75 percent of their initial inpatient work as consultations.  In Texas, outpatient consultation codes (99241-99245) pay between 29 and 55 percent more than new office patient codes (99201-99205).

On the inpatient side, admission codes (99221-99223) will be used in lieu of consultation codes. The "true" admitting physician will use a modifier along with their admit code, while all consulting physicians will use the admit code without the admit modifier. Who here thinks that physician practices are going to grasp this change by January 1 or that the minor increase in admit and follow-up RVUs will offset their loss of income?

The direct cost of this decision to your practice will vary as your consultation practice varies, but in any event, the effect is likely to be substantial.  For one local practice that I’ve been working with, the revenue loss across their four physicians is projected to be $87,000; a rough equivalent to 1.4 FTEs in their practice billing office.

At this time, I'm not aware of any other payer who has announced its intention to follow Medicare's lead, but as we are all aware, it is one of the easiest justifications to make, and if/when they do, the loss of income will be even greater.

In the mean time, you will have decisions to make and work to do. Physicians will have to use consultation codes for non-Medicare patients, but not for Medicare patients; or you can stop billing consultation codes for all payers and face the income reduction.  Then there is the real kicker, if your patient has Medicare as secondary insurance and you bill a consultation, Medicare will not pay you because it no longer recognizes the code submitted. If a patient has Medicare as secondary insurance and you bill a new patient code, Medicare will pay you, but at the lower new patient rates.

Like I stated in my ulcer code update blog......it is only money lol

Karr 

Well, this will affect me and many of you greatly, if you have a lot of Medicare patients (and I am guessing most of you do). 

I also sympathize some of my medical colleagues, ie. infectious disease consultants. Their practices are mostly based on the in-house (in-patient) consultations, and they are going to have huge pay cuts because of this change.

I don't do too much in-house consultations... it's maybe 5% or less of my total revenue. In the meantime, I am guessing that my ID friends will get something like 20% pay cut this year simply because the loss of these codes. It may be enough to make their practice unprofitable, and force them to go into early retirement. I'm dead serious about this!

I agree with Kazu, completely.

On the premise that common sense too one person is a revelation to another, insted of consultation codes providers have been instructed to bill:

 - initial hospital care 99221-99223
 - initial nursing facility care 99304-99306 or
 - initial office visits 99201-99205

Karr 

I would just like to add that this is going to be the problem with doing hospital consults:

According to medicare, if the attending/admitting physician does NOT attach their initial hospital evaluation 9922x series with an "-AI" modifier, then all subsequent consultants WILL NOT be paid for that patient's hospitalization.

This should be fun for those of us in the hospital systems...

Eric 

I've heard the reasoning behind the elimination of these codes (ex. decreased work for the doctors trying to get that written consult request).  I think it's nonsense.  This is obviously a money saving attempt by CMS.  The increase in reimbursement for the 9920_ codes is not close to the difference with the consult codes.  If it were just about paperwork then why not raise the "new patient" codes to what the consult codes were?  This is also indicative of the anti-specialist trend the government appears to be taking.  This goes right in line with the overall decreasing reimbursement for procedures and increasing reimbursement for primary care.  I don't have anything against our primary care colleagues being paid more (they're already underpaid and overworked) but why hurt specialists?  We have a much higher level of risk with surgery that requires more expertise and follow-up care that should be reimbursed appropriately.  The consult codes are not going to hurt primary care much (at least as much as it will us).

On a related issue how does everyone feel about the potential 21% overall medicare cut pending March?  Some sceptics say these cuts have been threatened for the past 5 or so years, but I wonder with the push for healthcare reform this one could actually get passed.  I think they're nuts.  Why cut physician reimbursement to make medicare soluble?  Why hurt the very people who are providing the care.  I can definitely understand the comment above that certain physicians will be pushed out of business.  Is this the healthcare reform we really want?  I don't think so.

From what I read in the past, the CMS decided that the consultation codes were "unnecessary and superfluous." This cracks me up as a lot of CMS documents are superfluous, if you ask me.

Again, this is one of those very insidious ways to cut back on our reimbursements. We just have to stay on our toes and make noise when we catch them in the act. It seems that they (the powers-that-be) have decided to pay more to PCP at the expense of surgeons and specialists. Unfortunately, I foresee in-fighting among specialties, mostly internal medicine vs. surgeons/specialists, on who gets how much cut of the "pie."

Food for thought... Japan (where I was born) has universal healthcare that is relatively competent and cost-effective. How do they accomplish it? The single payer (The Ministry of Health and Labour) under-pays and over-works the doctors and the hospitals to the limit over there. It may just happen over here, too. 

Kazu,

just to make another point, and this goes WAAAY back to our healthcare reform conversations, is that if they continue to cut the physician reimbursements, its not it genuinely affects most physicians in the northeast or midwest, but it severely hits the physicians in the south and southwest US.  This is obviously for a number of reasons, but it is where the largest pool of Medicare funds are spent per beneficiary.

So basically, if a proposed 21.2% cut was to be incurred, it would severely destroy my practice, which is 65% Medicare.  I cant absorb a one to one-hundred fifty thousand dollar loss.

Any other ideas???  Cuz the ones in Washington DONT WORK.