As the dust settles following the removal of the consultation codes from the 2010 Medicare fee schedule, a lot of questions remain. Unfortunately, some of the people trying to answer those questions are not providing sound coding advice. Most concerning is the idea that the outpatient consultation codes crosswalk directly to the office or other outpatient service codes.
The very first cross in this walk should raise questions. Could a 99241 service with key components of a problem focused history and exam and straightforward medical decision making realistically cross to a 99211 nursing visit? No. This service is much more likely going to meet the key components of a 99212 service. The difference is significant. The national average Medicare fee schedule amount for a 99211 is $19.12 while the national average amount for a 99212 is $38.97. By using someone's idea of a time-saving crosswalk rather than selecting the code that your documentation support, you could lose half the revenue your practice earned for this service.
Physicians should also be aware that hospital or nursing facility consultations that meet the key components of 99251 or 99252 do not satisfy the key components for 99221 or 99304, which require higher levels of history and examination.
The bottom line is that services should be assigned the code that the documentation supports. You should not cut corners by crosswalking the codes. This may be especially important to consider if you are billing a patient's private payer plan first and Medicare second. You may be able to bill the private plan for a 99251 service but you cannot bill that same code to Medicare for the secondary payment. In this case, you must determine whether your Medicare contractor will accept a subsequent hospital care code even though this was the physician's first inpatient encounter with the patient. They may require you to submit code 99499 for an unlisted E/M service instead, leaving them decide what level of service was rendered.
This move by Medicare to eliminate consultation codes from the fee schedule has shown just how complex E/M coding has become.Let's hope we can move toward a simpler system where physician work (i.e. level of history, exam, medical decision making, counseling and coordination of care) is fully valued with or without a request for advice or opinion. Now if there could be a closer look at all those E/M services valued into the global fees for surgery...
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights," featuring practical, peer-reviewed advice for improving practice, enhancing the patient experience, and developing a rewarding career.