CMS to Hold Physician Claims
The Centers for Medicare & Medicaid Services (CMS) has instructed its contractors to hold claims containing services paid under the Medicare Physician Fee Schedule (MPFS) for the first 10 business days of January (Jan. 1 through Jan. 15) for 2010 dates of service. CMS says this should have minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before Dec. 31, 2009, will be processed and paid under normal procedures.
After 10 business days, contractors will begin releasing held claims into processing under the fee schedule which implements current law. This, of course, could result in claims being processed with the negative 21.2 percent update. If a new law is enacted which changes the negative update effective Jan. 1, CMS will correctly process claims under the new law and, if necessary, CMS is prepared to automatically reprocess most of those claims which have already been processed at the lower rate.
Under the Medicare statute, Medicare payments to physicians and other affected providers are based on the lesser of the actual charge or the MPFS amount. Providers who submit charges that are greater than the negative 2010 MPFS will automatically have their claims reprocessed.
Medicare Eliminates Consultation Codes
Both the inpatient and outpatient consultation codes can no longer be used for Medicare patients effective January 1, 2010, and all medical practices, regardless of specialty, are affected. The Centers for Medicare & Medicaid (CMS) published the final rule in the October 30, 2009, Federal Register.
“The elimination of consultation codes will impact practice revenue. Some practices will see a decrease, while others may see a slight increase,” says Robert Cox, senior health care consultant with Anesthesia Resources.
Existing codes to replace consultation codes
| Old Codes | New Codes |
| Outpatient consultation (99241-99245) | New & established office (99201-99215) |
| Inpatient consultation (99251-99255) | Initial inpatient hospital (99221-99223) |
| Nursing facility (99304-99306) |
For the initial visit code, the admitting physician will need to append a modifier “A1” to identify him or herself as the admitting physician, while other providers will just bill the appropriate initial visit code without a modifier. This will be a change from the previous guidelines, which only allowed one initial visit code per hospitalization.
The monetary value of the consult codes was higher than the codes they’ve been replaced by, which will have a negative affect for most practices. “Understanding the financial impact this change will have on your practice is critical,” Cox says. “It’s important to do a complete analysis of your consultation, office visit, and initial hospital/nursing facility production under the new terms.”
RVU adjustments
Work relative value units (RVUs) have been adjusted to make this change budgetary neutral for CMS. As such, the work RVUs for the new or established office/outpatient codes will be increased 6 percent. For the initial hospital and nursing facility codes, work RVUs will be increased by 0.3 percent.
Non-governmental payer coding conflicts possible
One potential problem practices will face is that non-governmental payers don’t have to follow Medicare’s rule change. Most non-governmental payers will eventually move toward Medicare rules but many already have fee schedules established, Cox says. This discrepancy can make extra work to ensure correct reimbursement. For example, BlueCross BlueShield of Louisiana will continue paying for consultation codes through June 30, 2010; it will be determined at a later date whether it will continue to do so beyond this date.
Further complications could occur if an initial claim is filed to a carrier that accepts the consultation codes, but Medicare is the secondary carrier and will not accept the original claim as coded. To maximize the capture of reimbursement, practices will need to review both charge tickets and processes to make sure these evaluation and management (E/M) visits are billed properly.
How we can help
Using the crosswalk created by CMS to estimate the code shift, Anesthesia Resources can help your practice determine the impact the elimination of consultation codes will have on revenue and work RVUs.
For more information on the coding changes and our tool, contact Robert Cox, senior health care consultant, at robertc@anesres.com or 678-478-7866.
