As of January 1st, 2010, Medicare has ceased paying for any form of consult services. Some private insurance companies may continue to pay consults for sometime, but we can anticipate that all commercial carriers will eventually follow Medicare's lead in eliminating payment for consult services as well.
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THE CONSULT COURSE IN OUR MEMBERS' AREA HAS NOW BEEN UPDATED TO REFLECT THE NEW CMS RULES.
How do we bill for "consults" from now on?
Click on the image below to watch a 7-minute video about coding for consult services in a post-consult world.
To download our "consult" coding algorithm in .PDF format, click HERE.
IN THE OFFICE
In the office setting, we will have to bill for "consults" using the new office patient codes (99201 - 99205). However, if the patient has been seen by you or by another physician in the same specialty in your group within the previous three years, you cannot use the new office patient codes and must instead use the established office visit codes (99211 -99215).
IN THE HOSPITAL
In the hospital setting, things are somewhat more complicated. If you are "consulted" to see an INPATIENT in the hospital, you would bill for an H&P (initial hospital care) using the 99221, 99222 or 99223 level of care. The rules have now been changed to allow multiple "H&Ps" on the same patient by different providers. The admitting physician will attach a new modifier (AI) identifying them as the primary doctor for that hospitalization. Consultants should NOT attach this modifier.
If the patient is currently admitted under OBSERVATION status, he or she is technically considered to be an OUTPATIENT when it comes to E/M coding and billing. Therefore, if you are consulted to see an observation patient in the hospital, we have to use either the new office visit codes (99201 -99205) or the established office visit codes (99211 - 99215), depending upon whether the patient has been seen by the consulting physician or any physician in his or her group within the past three years. This is where the financial impact of the new changes wil likely be the most severe. For example, if a cardiologist gets called in to see a patient in the middle of the night for chest pain and the patient happens to be an observation patient and happens to have been seen by a physician from the same specialty in his or her group within the past three years, you would only be able to bill for an established office patients (maximum facility fee $99) as opposed to a high level consult (maximum facility fee $199).
IN THE ER
If you are "consulted" to come and see a patient in the ER, you first need to determine if the patient is going to be discharged or admitted. If you agree the patient can be safely discharged, you would bill your "consult" as an ER visit, just like the ER doctor. The rules have now changed such that multiple doctors can charge for ER visits on the same patient on the same day. If the patient is being admitted to YOUR service, you would do an admission H&P and attach the AI modifier. If the patient is going to be admitted by another doctor, you will have to find out if he or she is going to be admitted under observation status or as an inpatient. If the patient is admitted for observation, you would use either the new office patient codes or the established office patient codes (depending on whether or not the patient has been seen by you or your group in the past three years). If the patient is being admitted as an inpatient, you would perform and document your "consult" as an H&P (99221, 99222 or 99223) without attaching the AI modifier.