I suppose I can take down my article about ‘Did I Document a Consult?’ from the Intellicure members website.  You may not have noticed, what with healthcare reform, proposed Medicare cuts, "meaningful use," and the Red Flag Rule all taking center stage for the past six months, but Medicare made a recent decision to eliminate consultation codes.  Frankly, this decision may have a greater affect on your practice than any of these other issues.

This decision isn’t part of the HOPPS Final Rule which we’ve been discussing, but CMS' October 30 decision to eliminate outpatient and inpatient consultation codes, effective January 1, which will affect all medical practices, including the physicians who practice in your outpatient wound care center.  These plans are budget-neutral to the Medicare program as a whole, however they have the potential of crushing the bottom line of many practices.

Consultation code blues

Across the Intellicure Wound Registry, participating physicians code 10-15 percent of their new outpatients and more than 75 percent of their initial inpatient work as consultations.  In Texas, outpatient consultation codes (99241-99245) pay between 29 and 55 percent more than new office patient codes (99201-99205).

On the inpatient side, admission codes (99221-99223) will be used in lieu of consultation codes. The "true" admitting physician will use a modifier along with their admit code, while all consulting physicians will use the admit code without the admit modifier. Who here thinks that physician practices are going to grasp this change by January 1 or that the minor increase in admit and follow-up RVUs will offset their loss of income?

The direct cost of this decision to your practice will vary as your consultation practice varies, but in any event, the effect is likely to be substantial.  For one local practice that I’ve been working with, the revenue loss across their four physicians is projected to be $87,000; a rough equivalent to 1.4 FTEs in their practice billing office.

What about the other payers?

At this time, I'm not aware of any other payer who has announced its intention to follow Medicare's lead, but as we are all aware, it is one of the easiest justifications to make, and if/when they do, the loss of income will be even greater.

In the mean time, you will have decisions to make and work to do. Physicians will have to use consultation codes for non-Medicare patients, but not for Medicare patients; or you can stop billing consultation codes for all payers and face the income reduction.  Then there is the real kicker, if your patient has Medicare as secondary insurance and you bill a consultation, Medicare will not pay you because it no longer recognizes the code submitted. If a patient has Medicare as secondary insurance and you bill a new patient code, Medicare will pay you, but at the lower new patient rates.  We're working hard to get an update ready to deal with this situation, so if you're a client, we will have a billing solution done in time, but you will need to set some special custom keys.  We'll likely have all that done just before Christmas.  Happy Holidays!