As part of its 2010 Final Physician Fee Schedule Rule, Medicare has indicated that it will no longer for services coded as consultations as of January 1, 2010.Cardiologists provide many consultations and this change has caused many questions to appear.On December 15, 2009, CMS released more information on the changes to the consultation codes and how physicians should report services in 2010. To read the CMS MLN matters on this issue, please visit: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf

Q: Will I be paid for consultations provided to Medicare patients in 2010?
A: Yes, CMS has instructed physicians to report services that are now reported as consultations as office, hospital, or nursing facility visits depending on the setting.

Since cardiologists provide relatively few services in the nursing facility, we’ll focus on office and hospital services, but the rules for hospitals are the same as those for a nursing facility.

Q: Which hospital and office visits should I use?
A: CMS has indicated that physicians should use the initial hospital visit codes (99221-99223) for services that are provided as consultations in the hospital setting and new or established office codes (99201-99205 and 99212-99215) in the office setting.

Q: Aren’t initial hospital visit codes restricted to use by the admitting physician?
A: Currently, these initial hospital visit codes are restricted to use by the admitting physician.

If more than one physician were to submit an initial hospital visit code in the past, then the one that submitted it earlier would be paid and the second would likely be denied. However, this decision would change that rule. Physicians who are serving as consultants may use the initial hospital visit codes.

Q: Is there a crosswalk of the consultation codes to the office and hospital codes?
A: Physicians should select the level of hospital or visit code based on the documentation standards that are described in that section. In some cases, there is a direct correlation among levels of visits and in some cases there is not. For purposes of financial planning, ACC has made some assumptions about how services will be reported, but this will be different for every practice. In the hospital setting, there are five levels of inpatient consultation and three levels of initial hospital visits. The two lowest levels of inpatient consultation, which were rarely reported by cardiologists, have no equivalent in initial hospital visits. However the documentation standards for 99253-99255 and 9221-99223 are equivalent. Documentation standards for the visit codes should guide the coding.

Q: What is the financial impact of this change?
A: CMS estimates that the elimination of consultations will result in a 1 percent decrease in payments to cardiologists, but this number depends on your mix of services.

The decrease is not more significant because CMS took the money that had been paid for consultation services and distributed it to the office and hospital visits that will now be used to report them. This means that the payment for all office and hospital visits will increase as part of this change. For cardiologists who perform a large number of consultations, the financial impact may be very significant.

Q: Should I still report consultation services on patients with private insurance?
A: The ACC is communicating with major private payers to understand their intentions on the use of these services. Until you hear otherwise from your payers, you should continue to use the existing consultation codes for services provided to patients other than those on Medicare. The ACC has not yet heard from a private payer indicating that the company will discontinue acceptance of the consultation codes.

Q: How will Medicare know what physician admitted a patient?
A: Medicare has indicated that the admitting physician will be required to report a modifier in addition to the initial hospital visit on his or her claim. The required modifier will be AI. Only the physician who admits the patient should use this modifier on his or her claim for an initial hospital or nursing facility visit.

Q: If I admit the patient, do I continue to report the AI modifier on subsequent hospital care codes?
A: No, the AI modifier is only required to be reported once by the admitting physician and should be appended to the initial hospital or nursing facility visit only.

Q: I now provide consultations for established patients to review cardiovascular contraindications for surgical procedures. How will I report these services for Medicare patients in 2010?

A: For consultation services reported to established patients, physicians will have no choice but to report the established patient office visit codes, which are paid at a considerably lower level than consultations.

Q: How should I report a service provided to a patient in the emergency room?
A: Services provided to a patient in the emergency room would have been reported with outpatient consultation codes. While emergency department visits are most commonly reported by emergency physicians, they are not restricted by specialty. Physicians provided services in an emergency room should code those services as emergency department visits (CPT codes 99281-99285).

Q: How do I report a service provided to a patient in an observation setting?
A: For a patient in observation setting, a consultation should be reported as an initial or established outpatient visit (99201-99215) if another physician has reported the observation codes.

Q: What is ACC’s position on the elimination of consultations?
A: The ACC strongly opposes the CMS decision to eliminate the recognition of consultations. As ACC stated in its comments on the proposal when it was released, we believe that a consultation is a distinct service from an office or hospital visit which requires different skills and has a different typical patient. The ACC also has concerns about the administrative problems that could be caused by requiring different codes for different payers as well as other administrative issues. However, the ACC is committed to making sure that members understand the issue and are in the best position to avoid denials of payment and be recognized for their work.