Health Information Management

Tip of the week: Medicare change affects all consultation codes

APCs Insider, July 18, 2008

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As of January 1, under the OPPS final rule, CMS has assigned status indicator B to E/M codes representing consultations, which signifies a code that is not recognized by OPPS when submitted on an outpatient hospital Part B bill type. In other words, Medicare does not pay for the service represented by the HCPCS/CPT code under OPPS.

During 2007, Medicare indicated in the final rule that it might be unnecessary for hospitals to report consultation CPT codes if a new or established patient visit code accurately describes the service provided. Medicare requested input from providers by asking whether consultation codes were a useful measure of hospital resource use under OPPS. It also wanted to know, from a hospital perspective, how consultation visits differed from new and established patient visits.

Medicare?s real interest in considering whether consultation codes under OPPS should be separately payable with specific APCs was to identify additional ways to save money. Medicare stated:

We did not want to create an incentive for hospitals to bill a consultation code instead of a new or established patient code because we did not believe that consultation codes necessarily reflected different resource utilization than either new or established patient codes.

Accordingly, Medicare finalized a payment policy in 2007, whereby it assigned consultation codes to the same clinical APC as the established patient visit code for each level of service.

This year, Medicare took this payment approach one step further by changing the status indicator for all consultation codes to status indicator B, meaning that Medicare does not recognize the code under OPPS. Medicare also stated:

We do not believe consultation codes are a useful or necessary indicator of hospital resources under the OPPS. In addition, if consultation services were more resource intensive than established patient visits of the same level, our proposal would permit hospitals to factor this into their internal hospital guidelines that would determine the appropriate level of established visit to report.
For a discussion of E/M consultation codes in the final rule, visit the CMS Web site at www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms1392fc.pdf and see pp. 216?217. It is feasible for a physician to bill an E/M consultation code for professional services while the facility simultaneously bills a new or established E/M visit code.

Medicare may reconsider whether it should distinguish between new and established facility patients from a reimbursement perspective.

(This tip was borrowed from the July issue of APC Answer Letter. To view the entire article, click here.)



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