News: Elimination of consultation codes an opportunity for CDI specialists

Effective Jan. 1, CMS stopped paying for the CPT codes physicians use to bill consultations. This dramatic change provides a window of opportunity for CDI specialists, who are well-positioned to not only break the bad news to physicians, but also provide them with education on how to correctly document E/M visits that replaced the consult codes.

Here’s the news in a nutshell: CMS will no longer recognize consultation codes (ranges 99241-99245, and 99251-99255) for Medicare Part B payment. Effective for services furnished on or after January 1, 2010, physicians and non-physician practitioners should code a patient evaluation and management (E/M) visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. The appropriate CPT codes to bill are 99201-99205 or 99211-99215 in the outpatient setting, 99221-99223 for initial inpatient consult visits, and 99231-99233 for subsequent hospital inpatient post initial consults.

You can view the MLN Matters article on the changes at the CMS Web site.

“Carry copies of the Medicare Change Request document (CR 6740) with you. Physicians may not have time to read it, but give it to them and suggest that their billing staff and business office staff/office manager read it,” says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI. “Pulmonologists, renal, endocrinology, critical care, nephrology, it’s going to affect all of their businesses.”

Another tip: Offer to help physicians with accurate and complete medical record documentation in support of their E/M visits.

“You can say, ‘If you’re interested, as I review records, is it okay if I talk to you about some of the key points that you’re leaving out from the standpoint of medical necessity and medical complexity?’ I don’t think too many physicians would turn that down,” Krauss says.

CDI specialists can’t help physicians bill their visits. That would be considered an inducement, Krauss says. However, they can remind physicians of the importance of documentation of the patient’s severity of illness and nature of presenting problem and their relationship to E/M codes and medical necessity. Consider providing a PowerPoint presentation at a medical staff meeting using real cases documented by the physician staff.

“Change them around a little bit so the doctors don’t know whose notes they are,” he says.

For example, many physicians as consultants will document their initial consult visit with a fair degree of clarity and accuracy, but fail to document the need for additional inpatient visits. These subsequent visit(s) lack clinical documentation to support medical necessity and the reason for continued care, management, and billing.

“Each day of E/M services that a physician submits must stand on its own,” Krauss says.

“The focus should be on subsequent visits—the physicians need to document the medical necessity of why they came back [for subsequent treatment],” he says. “Medical necessity is partly based on the current diagnosis and management options. The second and third times, you wouldn’t have a history of present illness or a PSFH, you’d have an updated physical exam and you would also have your management thoughts on how the clinical impression may have changed and response to treatment, or additional drugs you might have used. And you should have a diagnosis on why you used those drugs.”

The above guidance promotes the same message that CDI specialists advance as part of their CDI program, but uses a different angle that physicians can relate to and appreciate, Krauss says.