Monday, January 04, 2010

The Unconsultation

Move over internists and hospitalists, I just completed my first "unconsult" - a "initial hospital evaluation and management visit" that was, until 1 January 2010, formerly considered a consultation in the eyes of CMS.

In the first glimpse of physician payment reform, we see that we are now being cloned as one in the same in the eyes of the government.

To coin a former beer commercial, I'm not sure if it tastes great, but it certainly is less filling.



Anonymous said...

what are you planning on doing when the secondary insurance is medicare and the primary insurance is still accepting consultation codes?

DrWes said...

anony 5:16PM-

I assume you are talking about Medicare Part B (the portion of Medicare that pays doctors' fees and for whom the billing codes become effective 1 January 2010) vs conventional insurance plans that might not have made the switch yet.

Since we are blessed to have an Electronic Medical Record (EMR) system, nearly all of the coding conversions are handled automatically by the EMR.

When a physician selects a consultation level of service for a Medicare patient, our electronic medical record system will automatically convert the consultation code to the appropriate evaluation and management (E/M) code for the place of service (office or inpatient). The conversion code has the same documentation requirements for history, exam and medical decision making as the consultation code and is compliant from a billing perspective.

In the outpatient setting, consultations will automatically convert to new patient office visits (99201-99205). In this scenario, if the patient has already been seen within the last 3 years by the physician in the same specialty and therefore does not satisfy the requirements for a new patient, a special claim scrubber logic program will identify this error and stop this encounter in a coding work queue for a coder to review. This process should ensure appropriate billing and reimbursement.

In the inpatient setting, consultations automatically convert to initial hospital care (99221-99223) for levels 99253-99255. Since Medicare has not been able to provide direction on the two lower consultation codes (99251-99252), how this will be handled remains up in the air. Those claims will be given an unlisted code until clarification is forthcoming from CMS. However, as long as you are completing the documentation requirements of a detailed history, a detailed exam and straightforward or low level medical decision making, you should be billing a level 3 (99253) or higher so utilization of the two lower levels should be limited.

Just to make it even more interesting and to accommodate the additional initial hospital care codes physicians will be billing, Medicare has created a new modifier, “AI,” to differentiate between the attending physician or principal physician of record and the consultant and will begin to reimburse for more than one initial hospital care E/M during a hospital admission. This modifier is used to indicate the attending physician and is reported only once per admission. Again, these new billing requirements will automatically be fulfilled by our EMR.

For doctors without an EMR, well, to put it bluntly, you're pretty much screwed trying to keep this all straight.

Hope that helps.

HSUY10 said...

Hi Dr. Wes,

Stumbled upon your site thru Medtronic's website. Absolutely fantastic information. Keep up the great work! I will be forwarding this blog onto my colleagues as well.

Maybe you should consider a blog with paid advertisements to offset some of the losses in the medical arena. Just a suggestion...


Anonymous said...

I may not agree with you but have to admit that you seem honest. If you get paid advertisements it may bias you opinion... just a thought.
Anyways how much impact will these consult codes have on cardiology, Maybe 20-40k?

The Happy Hospitalist said...

Question: When you admit a patient do you consider your services less valuable than when you consult on a patient? I ask this because our cardiologists admit most of their own patients into the hospital.

Doe that mean their training is less valuable to their own patients than when they consult on a patient admitted by another service?

Would love your opinion on that matter. Why should a consult be worth more.

Why should I as a hospitalist get paid more to consult on a patient for diabetes than if I admit a patient with diabetes.