Changes to OPPS Final Rule Eliminating Consultation Codes and the Impact on Healthcare Providers

Written by Lindsey Dunn | December 16, 2009

Social Sharing  

In its 2010 Outpatient Prospective Payment System Final Rule, CMS eliminated the use of "consultation" codes (CPT 99241-99245) for new patient consultations by specialty physicians. Starting in 2010, practices must bill for these services using regular evaluation and management codes (CPT 99201-99205 and 99211-99215), which reimburse at a significantly lower rate than the consultation codes.

Joshua Miller, RN, CCS, corporate director of charge capture for Continuum Health Partners in New York, discusses the change and how it will affect healthcare providers.

Elimination of codes
Specialty physicians currently bill Medicare differently for consultation, which is the initial consultation of a new patient following another physician's referral, and evaluation and management, which is the more straightforward, face-to-face evaluation and management of a patient's health, says Mr. Miller.

Both sets of codes reimburse for five levels of service, which are determined by the time required for the evaluation, the comprehensiveness of the history and exam, the complexity of the medical decision and the severity of the medical problem. However, the consultation codes reimburse physicians at a significantly higher rate.

CMS deemed the codes too similar and eliminated the consultation codes, but the move has upset many specialty physicians who see subtle differences in the codes and who will lose reimbursements due to the changes, says Mr. Miller. "Doctors see the move as a rejection of what has been a tenet of medicine — seeking out expert opinions. By eliminating the code, CMS is rejecting the value of expert opinion," he says.

The codes are unlikely to impact primary care physicians since they typically do not perform consults. Specialty physicians, however, are likely to notice reduced reimbursements from these high-volume codes. For example, a physician in Chicago is reimbursed $243.65 for a level 5 consultation and $161.82 for a level 5 evaluation and management service, a nearly one-third decrease in reimbursement, according to the Medicare Physician Fee Schedule. A physician in New York receives $259.19 for a level 5 consultation versus $171.49 for a level 5 evaluation and management service, a roughly 34 percent decrease.

Although the changes only currently affect Medicare billing, Mr. Miller expects that the elimination of consultation codes will eventually trickle down to other payors. As a result, many healthcare providers will eliminate the use of consultation codes with all payors, which will further eat away at their bottom lines. "Many organizations, including ours, see it as a compliance risk to bill Medicare patients differently from other patients," says Mr. Miller. "However less risk-averse organizations might only make the change for Medicare patients."

A bill was introduced in the Senate in early December to maintain the consultation codes for an additional year. However, it is unclear at this time whether or not the bill will be passed.

Learn more about Continuum Health Partners.

CPT copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

© Copyright ASC COMMUNICATIONS 2011. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.