A brand new year has begun, and that, as usual, means brand new surprises from our friends at the Centers for Medicare and Medicaid Services. This year's big surprise: The CMS has decided it will no longer pay for consultations in either outpatient (99241-99245) or inpatient (99251-99255) settings.

This decree has caused a great deal of protest, particularly from neurologists, rheumatologists, and other specialists who depend on consultations for a majority of their income. After all, specialists should be appropriately compensated for the special expertise they provide.

It is hard to envision how eliminating consultation payments could be anything but detrimental to patient care. At the least, consulting physicians may feel less inclined to provide reports to referring physicians, which will substantially hurt coordination of care at a time when policymakers claim to be looking for ways to improve it.

Further objections abound; nevertheless, the decision has been made, and adjustments must be taken to accommodate it.

For office visits, the CMS expects consultation codes to be replaced with new or established visit codes (99201-99205 or 99212-99215). They have increased relative value units for those visit codes by 6% to soften the blow, but the difference will be substantially noticeable if a lot of consultations were billed last year.

On the inpatient side, admission codes (99221-99223) are to be used in lieu of consultation codes. The “true” admitting physician will use a new modifier (not yet published at press time) along with the admit code, while all consulting physicians will use the admit code unmodified.

Physicians performing a lot of inpatient consultations should anticipate denials, appeals, and confusion as admitting physicians and consultants alike adjust to this change.

As usual, some commercial insurers will follow the CMS lead, while others will continue recognizing the consultation codes (which remain in the 2010 CPT book). This means a decision will need to be made about whether to continue billing consultations for non-Medicare patients whose insurers continue to pay for them. If this route is chosen, Medicare will provide secondary coverage, and will, of course, not pay its portion. So this situation needs to be recognized in advance.

It is probably worth reviewing some past explanation of benefits to determine how often Medicare is a secondary payer, and whether any extra revenue will be worth the extra vigilance and work involved.

Discussions on this issue have been widespread and heated, and opinions vary widely.

Some specialists claim they actually welcome the change because they will no longer need to worry about complying with the CMS's confusing and ever-changing consultation rules.

Others are understandably concerned about a potentially significant loss of income. Do not be tempted, however, to bill for more services, such as biopsies and surgical procedures, as compensation for lost revenue. The CMS is well aware of that tendency (they even have a name for it: “code creep”), and they will be watching.

If billing patterns change significantly, an audit can be expected; increased billings must be proved to be of medical necessity, not compensatory revenue generation. If increased billings cannot be proved to be medically necessary, abuse or fraud charges will come. In an audit, remember, everyone is guilty until proven innocent.

Billing patients directly for consults has been proposed as a way to recover lost revenue. If consults are no longer covered by the CMS, physicians have reasoned that they should be able to use a “noncovered service” code (such as 99199-GA) and have Medicare patients sign an Advance Beneficiary Notice (ABN). This signifies their understanding that Medicare will not pay for the service, the same procedure used for noncovered cosmetic services. It is not clear, however, if this is permissible by the CMS.

Another proposed counter strategy is to bill Medicare for a new patient visit and add a “surcharge” for consultative care, billed directly to the patient (again using a National Supplier Clearinghouse [NSC] code and an ABN). This would be considered a “priority service,” analogous to “concierge services” offered by some internists. No one knows if the CMS (or patients) would go along with this option either.

Even proponents of such strategies admit they are speculative and untested; I would not advise attempting them without a careful legal review with an experienced health care attorney.

No matter how individuals choose to deal with the loss of consultation codes, I believe physicians should continue sending reports to referring physicians even though they will not specifically be paid for them.

Doing what is best for patients should always be the top priority.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Farewell Consultation Codes