As you know, CMS dropped a bombshell the other day onto the physician community by suggesting they are going to eliminate consultation codes from the Evaluation & Management (E&M) arsenal. If you've been reading anything over the last 20 months, you will know I find myself highly knowledgeable about the coding system that is the disdain of physicians everywhere.
Consultation codes exist in both the inpatient and outpatient spectrum of care. For inpatients, there are five of them, CPT codes 99251-99255. For out patients, there are five of them as well, CPT codes 99241-99245. A consult generally requires the 3 Rs.
- Request. You must document the requesting physician
- Reason. You must document the reason for the consult
- Response. You must respond (usually a carbon copied dictation) to the requesting physician
If we get rid of consult codes, be prepared to lose the 3 Rs. That may or may not be a good thing depending on your view of excess documentation requirements and built in inefficiencies of E&M.
You can see much more here in my coding lectures or earn CME at E&M University.I am going to go out on a limb and suggest that the elimination of consultation codes is just the beginning. I am going to suggest that CMS ultimately has the entire elimination of the Evaluation & management fee for service system on the chopping block in an effort to move toward bundled care schemes for all physicians which will pay physicians to take care of patients, not encounters with patients.
With that said, I wonder how much money will be saved and redistributed from eliminating consultation codes. And I might suggest that eliminating consultation codes could increase overall costs due to unintended consequences. Based on their news release I can't figure out They are going to allow admission codes (99221-99223) to substitute for the consultation codes they are removing (99251-99255).
Let's look at the inpatient codes: Let's assume every in patient consult that is done meets level five criteria. In my state a level five consult code (the highest/99255) pays about 5.5 RVUs or $190. A level three admission code 99223, the requirements of which are identical to the 99255 consultation code pays about 5 RVUs or $170 dollars. That represents a savings of $20 per consult if consultation codes were substituted with admission codes .
Let's look at the inpatient codes: Let's assume every in patient consult that is done meets level five criteria. In my state a level five consult code (the highest/99255) pays about 5.5 RVUs or $190. A level three admission code 99223, the requirements of which are identical to the 99255 consultation code pays about 5 RVUs or $170 dollars. That represents a savings of $20 per consult if consultation codes were substituted with admission codes .
CMS will allow consultants (that includes me too when I'm being asked to evaluate subspecialist patients in the consultation role) to use the admission codes when asked to evaluate a patient. But, if they only allow us to use the hospital follow up codes (99231-99233), an equivalent level three hospital follow up code (99233) pays just over 2.5 RVUs, or $90. That's less than 50% of the high level consult code that pays $190
As you can see, the savings could be anywhere from just over 10%-50%, depending on which codes are considered "existing". And this savings would be redistributed into the existing E/M codes to increase payment rates.
CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.
What that means is all doctors who do E&M follow up or admission codes will experience a raise. That includes the subspecialists as well, since most of them continue to follow along on a daily basis once the initial consult is done. I do not think this represents a significant reduction in physician payment for subspecialists, because more will be collected on the follow up codes.
You can see much more here in my coding lectures or earn CME at E&M University.
However, the unintended consequences of this action may make physicians stay on board in a consultation role for periods of time longer than is medically necessary thereby increasing total overall costs. And nobody can tell you when signing off is appropriate. This is done on an individual basis based on the patient and the physician. It will always meet medical necessity muster. I have never been denied payment because I didn't sign off a case soon enough. I blog always that I could create medical necessity out of thin air. It is a utopian concept that can not be codified or quantified. My service was medically necessary because I said it was. That is essentially the standard.
When a physician "signs off" a case is completely arbitrary. As a hospitalist, I have patients being followed for weeks by subspecialty consultants who add nothing of significant value on a daily basis. If the consultation codes are removed, it may mean a further delay in signing off the case, especially if those codes are paying a higher rate. And that folks means higher costs for everyone, including the Medicare National Bank.
Lets look at the outpatient model. The highest outpatient consult (99245) in my state pays just over 6 RVUs or $210. There is no equivalent admission code for an outpatient consult. The closest equivalent is a high level outpatient follow up visit (99215) which pays 3.5 RVUs, or just under $120. A significant reduction in fee. Since I don't work in outpatient medicine, perhaps those of you still reading this far could comment on what affect that would have on patient care. By nature, a consultant needs either a referral from a family medicine doc or an internist, or a self referral from a patient. How will this affect a consultants mindset in outpatient care?
Ultimately, every action has a consequences. In this fee for service system we live in, every action will drive volume, which drives revenue, which drives income, which in our capitalistic society, will attempt to buy happiness. Which we all know, at least I do, will never happen.
You can see much more here in my coding lectures or earn CME at E&M University.
You can see much more here in my coding lectures or earn CME at E&M University.
6 Outbursts:
Anon #2 and the happy hospitalists
The general concept that a PA/NP is unable to provide any real value when performing a consultation is arrogant. There are good doctors and bad doctors, as well as good and bad PA/NP, nurses, dieticians, etc. It's like stating that if PA/NP's were smart enough then they would have been a doctor, and all good nurses should have gone to PA/NP school if they were just intelligent enough. I have worked with a number of doctors who I personally wouldn't send my dead cat to, knowing that it still had 8 more lives left. There are varying degrees of competency within all of the disciplines; with I believe less numbers of outliners, the more education/experience they have. That being said, I would rather see a Dr/PA/NP with less experience who is up to date with medicine than a doctor who hasn't read an article in years above what is mandated to keep his/her license active. I think the secret is finding out who are the Dr/PA/NP’s who know their stuff.
Another point that subspecialists wouldn't hire PA/NP if reimbursement for consultations is decreased is also flawed. Do you think a surgeon would want to work harder to save a little money? I have had surgeons tell me that "WE" don't make them any money, but because it makes their lives easier that we are worth hiring. I don't think that paying a mid-levels salary would compensate for the added work that they would be required to perform if we were not around. Specialists all like money foremost, but from what I've seen lifestyle isn’t far behind.
anon1132, perhaps you forgot to read my post. I was discussing PAs and NPs who work in a capacity as just data gatherers. If you don't know they exist, trust me, they do.
I think that's a shame. You don't need an NP or PA to gather data. You could do that with a nurse. If you're going to hire an NP or PA, you should give them some decision making capabilities.
anon #2. Tell that to all the subspecialists who use NPs and PAs as consult generators, dictators, physical examers and history takers.
anon #1. thanks for clarifying the new patient codes. I had forgotten about them. I looked up the payment differences in my state for a 99245 outpatient consult vs a 99205 out patient new patient.
For the consult done in the office, it pays a little under 6 1/2 RVUs total,in dollar amount about $210.
For a new patient evaluation in the office, it pays about 5 RVUs total or about $170.
About a 20% haircut.
I would say that constitutes a significant reduction in payment.
I might suggest another uninteded consequence is because consults require the 3 Rs and new patients don't consultants may stop sending letters or consult notes to the family medicine or internist doc because they aren't required to do so.
Or perhaps they may still do so to keep their referral base up.
Just one more thing to consider.
np/pa ability to contribute to inpt consult is very limited. if they participate beyond the permitted areas, should not be billed as a consult anyways.
Happy, your hospitalist bias is showing. Outpatient/office E/Ms aren't considered "admissions," but "new patients." And there is a new patient equivalent, at least level-wise, to a 99245: a 99205, which is 3 work RVUs (because of site-of-service differentials, I'm not including malpractice or practice expense RVUs here) to a 99245's 3.77.
A patient is considered "new" if s/he hasn't seen a physician in the same subspecialty billing under the same tax ID in 3 years. So a pcp in a multispecialty internal medicine group can refer a patient to cardiology (or endocrinology, or whatever) and the specialist can bill it as a "new" patient. Currently, a lot of new patient visits are being billed as consults, but the documentation is lacking (esp the last R) to truly be a consult.
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