14 Points About the End of Consultation Codes and Onset of Lower Reimbursements for Orthopedic Surgeons and Other Specialists

1. What is about to happen. On Jan. 1, 2010, Medicare will stop accepting consultation codes to bill for referrals. In place of the old codes, practices will have to use existing CPT codes for new or established patients in the office setting and for initial hospital care and subsequent visits in the hospital.

2. There will be no transition period. Medicare payors will reject the old consult codes as invalid starting Jan. 1, 2010. They won’t translate the old consultation codes into the new codes.

3. This change will affect most orthopedic billings. A typical orthopedic practice currently uses consultation codes for more than 50 percent of new patient office visits and virtually all of its inpatient visits.

4. Orthopedic practices will lose money. Orthopedic surgeons are expected to see an average reduction of 20 percent in reimbursements for services that have been billed with the old consultation codes. The specific reduction will vary from 8-30 percent, depending on the setting and the coding level. See the chart at the end of the story.

5. Medicare will save more than a half billion dollars. Changing ambulatory consultation codes to those for new patient visits is expected to save Medicare $534.5 million per year. With that kind of money on the table, private payors may eventually follow Medicare’s lead and drop consultation codes but they will not do so right away.

6. Practices will have to deal with two different coding systems. Private payors are expected to continue using consultation codes, at least for now. This means that practices will have to distinguish between consultations for Medicare patients and those for others. Eliminating the confusion by using consultation codes for private payors is not a good option because the bills may be denied and, if accepted, would be reimbursed at the lower rates.

7. Changes in outpatient codes in a nutshell. In the office setting, consult codes 99241-99245 will be replaced by the regular codes for a new or established patient visit. Patients who have been seen by the surgeon in the past three years are billed as a regular office visit (99212-99215) and all other patients are billed as a new patient visit (99201-99205), which pays a little more than a regular office visit.

8. Changes in inpatient codes in a nutshell. In the inpatient setting, consultation codes 99253-99255 will be replaced by initial inpatient patient visit codes 99221-99223 or subsequent visit codes 99231-99233. In the nursing home setting, consultation codes 99251-99255 will be replaced with codes 99304-99310.

9. Deciding the right level inpatient code remains unclear. The old and new coding systems do not appear to have the same criteria for each levels of the initial hospital visit. CMS’ guidance does not appear to clear up the problem. Practices can consult AMA’s CPT Assistant, and the regional MACs and carriers may clear up the confusion.

10. PCPs and specialists use the same codes for hospital visits. The primary care or other physician who admits the patient will be designated the “primary physician,” who uses the same billing code as the specialist but with a modifier attached that has not yet been identified by Medicare. All specialists involved in the case will be designated “secondary physicians” and do not need to put a modifier on their codes.

11. Telemedicine will still use the consult codes. Telemedicine will be the only area where consultation codes will still be used, but they will be changed to three new G codes: G0425, G0426 and G0427.

12. Some practices who want to exit Medicare have two choices. They can choose to be “non-participating” or “opt out.” A non-participating physician can bill Medicare patients at 9 percent higher than Medicare participating rates, but Medicare reimburses the patient and the office then must collect from the patient. Physicians who opt out have to give the carrier 30 days notice and can only leave at the beginning of each quarter: Jan. 1, 2010; Apr. 1, 2010; July 1, 2010; or Oct. 1, 2010. The physician can still treat Medicare patients but they would not be reimbursed by Medicare.

13. A last-ditch Senate proposal would preserve consultation codes. Sen. Arlen Specter (D-Pa.) introduced a proposed amendment to the Senate healthcare reform bill on Dec. 11 that would preserve consultation codes. It was introduced at the request of several specialty societies and the AMA. In a survey of members of the American Association of Clinical Endocrinologists, four out of five said they would drastically reduce or eliminate the number of Medicare patients if the codes were eliminated.

14. Chart showing decreased reimbursements. The following chart shows decreases in reimbursement by each code, based on changes in relative value units (RVUs).

*Codes are for new patient visits. Codes for a regular office visit (99212-99215) will be used if the patient has been seen in the last three years.
**Based on key elements required, not using time.

The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.