Eliminating Consultation Codes Has Unintended Consequences.

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.   Consultation codes exist in both the inpatient and outpatient spectrum of care. For inpatients, there are five of consult codes:  CPT® codes 99251-99255.   Review the AMA's CPT 2015 Standard Edition as the definitive authority on CPT® codes.  It is linked below and to the left from Amazon.  For outpatients, 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.
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 they are going to allow the initial 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.

As you can see, the savings could be anywhere from just over 10%-50%. 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 initial admission codes will experience a raise. However, the unintended consequences of this action may make physicians stay on board in a consultation role for periods of time longer thereby increasing total overall costs.  When a physician signs off a case is completely arbitrary. 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 and unintended consequences as well.

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2 Outbursts:

  1. 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.

    - Evil Administrator

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  2. 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.

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