Reducing Compliance Risk- Strategies for Medicare Consultation Billing 2010 AAHAM Keystone Educational Meeting February 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 , and ). 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 –Subsequent hospital visit codes – Nursing facility care codes; –Initial nursing facility care codes –Subsequent nursing facility care codes – 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 –Established patient codes

Emergency Department Consultations Utilize Emergency Department codes that describes the services provided in the Emergency Department; –Emergency Department Visit – 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 Established patient codes – 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