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Deleting Medicare Consult Code Could Hurt Patients, Say Doctors

 |  By HealthLeaders Media Staff  
   December 04, 2009

A Medicare rule that will eliminate specialist physicians' ability to bill higher amounts for patient consults as of Jan. 1 "has caused a combination of panic and confusion" and should be postponed for a year, the American Medical Association wrote in a lengthy letter.

"Without such a delay, we anticipate payment denials, re-submissions and appeals that could create claims backlogs, cash flow problems and increased costs that could lead some physician to avoid Medicare patients," wrote Michael D. Maves, MD, AMA executive vice president, in a Nov. 25 letter to Jon Blum, director of the Center for Medicare Management of the Centers for Medicare and Medicaid Services.

The impact will be even worse "if Congress has not acted to prevent a scheduled 21.2% cut in the conversion factor that is scheduled to take effect on Jan. 1," he wrote.

Maves wrote that without a delay to educate doctors and consider the implications of the change, "two potential unintended consequences" will occur.

"First consulting physicians may stop accepting Medicare patients referred for consults. Second, more and more consultants may stop interpreting the findings in the medical record in a report back to the referring physician.

"Each scenario presents significant care coordination concerns and while CMS says it will be on the lookout for any unintended impact the new policy could have on care coordination, some real damage to individual patients could occur while CMS is still in monitoring mode."

Maves told Blum that "physicians will experience claims denials, audits and repayment demands, and conflicts with secondary payers simply for following the rules that CMS has laid out. Increased frustration and costs for physicians, payers and patients seem sure to follow."

Under current CMS rules, the CPT code for consultation calls for reimbursement that is between $20 and $50 higher than for a comparable office visit.

CMS officials has not responded to requests for comment.

Mapes met with CMS officials Nov. 24 about the elimination of CPT codes 99241-99244 for office or other outpatient consults and 99251-99255 for outpatient consultations. "Rather, CMS has instructed physicians to bill using the new or established patient codes instead."

Physicians who are concerned about the change say the elimination of these codes will necessitate substitution of evaluation and management codes, which pay significantly less.

"Unless the January deadline is moved back significantly, we do not see how Medicare will have sufficient time to educate physicians about the new modifier or to develop and widely distribute guidance —including a crosswalk —on how to use the visit codes. Time is also needed to educate secondary payers and provide them with enough time to handle impacted crossover claims."

Maves wrote that CMS rejected the AMA's CPT code panel's new language that would have clarified how consultation codes should be applied. "CMS apparently is rejecting this effort because there was not ‘universal agreement' among physicians on what the appropriate policy should be.

"Yet CMS' substitute policy has far less acceptance among physicians and has not been subjected to the cross-specialty scrutiny that could have identified and avoided some of the confusion and concerns the new policy has engendered among physicians."

The AMA's House of Delegates in November called for a repealing the new policy altogether.

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