reducing compliance risk- strategies for medicare consultation billing 2010 aaham keystone...
TRANSCRIPT
Reducing Compliance Risk-Strategies for Medicare
Consultation Billing 2010AAHAM Keystone
Educational MeetingFebruary 18, 2010
2
Agenda
• Introductions• Overview of 2010 Consultation Code Changes
– New Billing Guidelines– Hospital/Nursing Facilities– Office or Outpatient Services
• Third Party Payer Impact• Questions?
Consultation Code Changes 2010
• Effective January 1, 2010, Medicare will no longer recognize AMA CPT consultation codes (ranges 99241-99245, and 99251-99255).
• Effects both inpatient facility and office or outpatient settings where consultation codes were previously billed.
• CMS maintains that the change is budget neutral.
Why Discontinue Consultation Codes?
• “Rationale for differential payment is no longer supported because documentation requirements are now similar across all E&M services.”
• Confusion regarding use of consultation codes.• Unable to achieve sustainable improvements subsequent
to education efforts.
Overview of Changes
• Physicians and qualified NPP’s use E&M codes to report consultations based on:– Where services take place;
• Exception - Observation
– Complexity of Service
• Utilize the code that most appropriately supports the level of service that the Physician or NPP provided and documented.
Inpatient/Nursing Facility Consultations
• Hospital E&M codes;– Initial hospital care codes - 99221-99223
– Subsequent hospital visit codes – 99231-99233
• Nursing facility care codes;– Initial nursing facility care codes - 99304-99306
– Subsequent nursing facility care codes – 99307-99310
• Admitting physician appends modifier “AI”– No payment differential
– Identifies the physician who oversees patient’s care from the other physicians who may be furnishing specialty care
Observation Service Consultations
• Evaluation of Observation patient while in Observation status;– New patient codes - 99201-99205
– Established patient codes - 99211-99215
Emergency Department Consultations
• Utilize Emergency Department codes that describes the services provided in the Emergency Department;– Emergency Department Visit – 99281-99288
• If patient is admitted to the hospital by consultative physician, the consultative physician should bill an initial hospital care code.
Outpatient Consultations
• Office and other Outpatient E&M codes;– Depending on complexity of patient;– New or established patient to the physician;
• New patient codes - 99201-99205• Established patient codes – 99211-99215
• New patient versus established patients identified by:– New patient – No professional face-to-face services by physician or
practitioner of same specialty within group with 3 years.– Established patient – Professional services to patient within past 3
years;• In the office;• In the office with different diagnosis;• Other setting.
Third Party Payer Implications
Medicare is Primary or Secondary• Must use appropriate E&M code to bill Medicare.• If primary payer recognizes consultation codes, provider
can;» Bill primary with applicable E&M code and submit
secondary claim to Medicare;
» Bill primary payer with consultation code, then report actual amount payment along with E&M code that is appropriate for the service to Medicare.
Operational Strategies – Getting it Right Up Front
• Update all fee slips/encounter forms• Update all inpatient cards• Develop educational materials to explain changes to physicians,
support clinicians, coders and revenue cycle personnel. • Research major Third Party Payers consultative billing rules;
– Medicare HMO products– Non-Medicare Products
• Develop coding matrix for Business Office relative to Third Party Payer crosswalks
• Implement edits within billing system
CMS Guidance
Med Learn Matters;
MM6740 dated December 14, 2009
Additional Questions