Medicare Proposes Ending Payment for Consultation Codes
The Proposed 2010 Medicare Physicians Fee Schedule Rule released by CMS last week included a bombshell hidden in amongst the 1128 pages: a proposal to discontinue reimbursement for the E/M consultation codes (CPT 99241-99255). These codes have been problematic for both physicians and insurers due to confusing and sometimes conflicting rules governing their appropriate usage. Over the years, Medicare has made numerous clarifications and code description changes to resolve the confusion. Now Medicare has decided to do away with the use of these codes altogether. Since consultation codes are reimbursed at significantly higher rates than regular office visit codes, CMS has proposed to increase rates for the remaining covered E/M codes to not penalize doctors while maintaining budget neutrality in their payments. If this proposal is implemented in November, it will become important that all physicians review their charges for E/M services (for both Medicare and commercial carriers) to ensure they are not undercharging Medicare for these visits and are in coding compliance if commercial insurers continue to pay for the consultation codes.
How To Select a Third Party Billing Entity
Selecting a third-party billing entity (“TPBE”) can be a difficult process for medical group administrators and their organizations. A TPBE usually offers medical billing services, which may include charge-data entry, billing, electronic claims submission, payment posting and collection follow-up.
Upon beginning a search for a TPBE, a medical group must first set its own priorities and determine the services it needs. The following are some important things to consider regarding TPBEs:
1. Size. Large TPBEs typically have the benefits of in-depth compliance programs, multispecialty expertise, many employees, cross-training, and the ability to offer additional services. However, large TPBEs may also include higher TPBE overhead costs, inconvenient locations, and the potential for high employee turnover.
Small TPBEs typically have the benefits of lower prices and less overhead, more personalized service, quicker response time, and potentially more control for the medical group. On the other hand, they may only have limited compliance plans and limited multispecialty expertise, there may be coverage issues due to fewer employees, and they may offer fewer services.
2. Scope of Services. The medical group should decide whether it wants to pay extra for services such as record storage, computer equipment, software upgrades, ad-hoc reports, correspondence backlogs, and in-person representation for appeals with payers.
3. Billing. The group should decide how to be billed: per transaction or per claim? By a flat monthly fee or a percentage of practice revenue collected? It is important to ask vendors for samples of management reports such as accounts receivable, charges billed, collection/revenue, denied claims, credit balance, and contractual and other write-offs. Vendors should also be asked for a list of policies and procedures, a sample contract, and a tour of the facility.
Finally, before entering into a contract, the medical group should refer to the Department of Health and Human Services’ Office of Inspector General’s guidelines for TPBEs (http://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf) to ensure vendor compliance.
It is a good idea for medical groups to include specific terms and agreed-upon standards in the contract for the following: (1) maximum average number of days in accounts receivable; (2) maximum number of charge lag days; (3) other benchmark numbers important to the group; and (4) consequences if the TPBE does not achieve the stipulated benchmarks. The group will need to provide the TPBE with accurate billing and patient information so that both parties can meet the terms of the contract. Knowledge on both sided will greatly help to build a successful long-term billing arrangement.[1]
