The ACP Advocate Blog

by Bob Doherty

Tuesday, August 11, 2009

Does CMS Proposal De-value Physicians Who Consult on Other Physicians' Patients?

Advocate Blog Guest Blogger: Brett Baker, Director of Regulatory and Insurer Affairs

CMS has recently proposed that Medicare no longer recognize the Current Procedural Terminology (CPT) codes describing office/outpatient and inpatient consultations. If the CMS plan takes effect in 2010 as the agency proposes, a physician will bill Medicare for an office consult using a new or established patient office visit code (99201-99205; 99211-99215) and bill an inpatient consult using an initial hospital care service code (99221-99223).

CMS would take the money that it currently spends to pay for the consult codes (99241-99245; 99251-99255) and distribute it to increase payment for the codes that "replace" them. While other CMS-proposed changes impact the 2010 Medicare payment rate for office visits and initial hospital (and initial nursing facility) care, this results in a slight increase in payments for these services. Assuming, for the sake of simplicity, that the 2010 payment cut from the flawed SGR is averted and that the 2009 conversion factor remains the same for next year:

* Medicare 2010 payments for initial hospital care services will generally be lower than the 2009 inpatient consult payment rates.

* Payments for office visits will be less than for office consults, and significantly less if the beneficiary is an “established patient” known to the consultant. For example, Medicare will pay $103.16 for a mid-level new patient office visit and $68.89 for a mid-level established patient in 2010; it paid $124.80 for a mid-level office consult in 2009.

The highlights of the agency-provided rationale for its proposal are below.

CMS states that physicians have a hard time billing consults correctly because the distinction between a consult and a transfer of care continues to be unclear.

CMS states that the physician work associated with a consult and an office visit/initial hospital care service is "clinically similar." Further, the agency states that the historically higher payment for a consult was primarily because of the requirement that the consultant provide a formal written report back to the requesting physician. It asserts that a significant discrepancy no longer exists now that the consultant's report can take any written form.

The agency notes that the increased payment for office and initial hospital visits would benefit primary care physicians - as they provide relatively few consults, although it stopped short of citing that as an explicit reason for its proposal.

CMS is accepting comments on this proposal (and other changes to the Medicare physician payment schedule for 2010) from the public through August 31. ACP is determining how it will respond to the agency. The College and other physician organizations have feuded with CMS since the agency expanded its definition of what constitutes a transfer of care - which narrowed when it is appropriate to bill a consult - three years ago. While ACP is skeptical of the CMS, especially considering this recent history, it is taking the time to evaluate the surprise proposal

Today's question: Is the physician work involved in furnishing a consult "clinically similar" to an office or initial hospital care visit to the point that no payment differential is warranted?

3 Comments :

Blogger kidney doc said...

This is yet another example of bureaucrats playing with codes and numbers and reimbursement instead of focusing on appropriate compensation for non-procedural( "cognitive") services.

The issue truly is how big is the problem and how much time was spent and forget about the artificial separation between a consult and a complete evaluation.

gary kardos

August 14, 2009 at 11:53 AM  
Blogger Christie said...

These fools confuse busy work with in-depth knowledge, extensive experience, and clinical judgement honed over years of patient care. As a cardiologist, I recognize, for example, an athlete's heart with extensive T wave inversion in a healthy black man. The computer reads the ECG as "extensive ischemia", the PCP says to the patient "You have a serious heart problem", and I have to straighten it out. Half the time I spend in a consultation is spent in patient education and and increasing their understanding. The bureaucrats cannot quantitate expertise or judge excellence of care. Am I an elitist? You bet I am. And so are you. You are a pro and need to stand up for yourselves.

August 17, 2009 at 8:32 PM  
Blogger farnandas said...

This results in a slight increase in payments for these services. Assuming, for the sake of simplicity, that the 2010 payment cut from the flawed SGR is averted and that the 2009 conversion factor remains the same for next year:

https://www.carlmontpharmacy.com

October 6, 2012 at 4:05 AM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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