Consultations: Is this the last year?

When to bill a consultation vs. a new or established patient visit in the office or in a hospital setting has been a topic of conversation and debate at seminars for several years. 


The guidelines in CPT and from Medicare are ambiguous and of course the payment differential of approximately $40 per visit has lead to suspected mis-payments, audits, take backs and fines.  In July the Center for Medicare and Medicaid Services (CMS) offered a proposed solution to the debate that is a bit radical.

CMS proposed to eliminate payment for both Outpatient and Inpatient Consultation codes for 2010 and beyond.  If they do this CMS has proposed increasing new and established patient visits as well as initial inpatient visit code values to maintain budget neutrality.   In addition CMS has proposed changing the rules allowing any physician to bill an Initial Inpatient Hospital Visit the first time a patient is seen in the Hospital setting and they have proposed creating a modifier to distinguish the admitting physician from others.

On the surface the proposal would seem to make life easier as you will no longer have to develop specific documentation or meet the requirements of noting the requesting provider or communicating in writing.   From a financial standpoint, those visits previously billed as Consultations will be reduced by an estimated 20-38% depending upon the level of service reported.

The move is couched in the form of eliminating a problem within the system that the OIG has estimated caused $1.1 billion in overpayments and is a headache for providers.  If you look beneath the numbers from the OIG 47% of the errors were wrong category or wrong level errors and 19% of the estimated 75% error rate were codes that did not meet the consultation criteria.   Although arguing that the consultation criteria are clear and easily understood is folly, elimination of these codes which are valued to include the cost of developing correspondence to the referring physician is yet another cost shift providing more money to primary care at the expense of specialists.

We encourage all of you to comment on the elimination of consultation codes.  Comments will be taken by CMS until 5 pm Monday August 31, 2009.

You can frame your comments as you wish, however, we see there are two potential avenues to take. 

1)    The consultation codes should remain in force.  The values were developed to include the costs of writing and sending communication to other providers and these costs remain for the majority of practices or have been shifted to the costs of maintaining an EMR.

2)    If the consultation codes are eliminated the budget neutral application of money saved should be expanded to all services and not focused on E/M codes alone.  

There are four ways to submit your comments two of which are listed below:

1. Electronically. You may submit electronic comments on this regulation to [Link no longer available]. Follow the instructions under the “More Search Options” tab.

2. By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-1413-P,

P.O. Box 8013,

Baltimore, MD 21244-8013

Please allow sufficient time for mailed comments to be received before the close of the comment period.

You can also contact Cathleen Scally, (410) 786-5714 for additional information if you choose.