Saturday, January 2, 2010


Quick... Hold on tight, as the changes for 2010 in CPT are coming in fast and furious. I had some GREAT e-mail and updates from my Friends @ PHIA to help us through the murky "consultation" issues for 2010. In addition, they have GRACIOUSLY allowed me to link and forward this info to you! (THANK SO MUCH NICKY AND SHERRY!)

This is direct from the PHIA "newsflash"

In the calendar year 2010 physician fee schedule final rule with comment period (CMS-1413-FC) CMS budget neutrally eliminated the use of all consultation codes for various places of service except for telehealth consultation G-codes. Effective date of change is January 1, 2010, with implementation to begin on January 4, 2010. Click on this link (or cut/paste into your browser) to see the entire transmittal : )

·CMS increased the work relative value units (RVUs) for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our practice expense PE and malpractice calculations.

·In the inpatient hospital setting and the nursing facility setting all physicians who perform an initial evaluation and management may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

·Modifier “-AI,” defined as “Principal Physician of Record,” shall be used by the admitting or attending physician who oversees the patient’s care

·In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer.

·Contractors must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).

·The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.

·When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code for the initial hospital admission. Contractors pay the office visit as billed and the Level 1 initial hospital care code.

·Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

·For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.

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One thing to keep in mind when billing out services with the new AI modifier is that this modifier is specifically for use with Medicare/Medicaid claims. If you are billing to a private payor, you will want to find out if the payor recognizes this modifier.

Consultation codes are still a valid code within CPT, but do not have RVU's associated with them. You will also need to check with your private payors to see if they will continue to recognize the consultation codes, and pay you for them. If they do, be sure to follow all CPT guidelines for usage of the consultation codes.

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