To provide urologists with the best two minutes of their practice week with practical information on coding, billing and practice management issues related to urology.
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Written by M. Ray Painter, MD
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Monday, 11 January 2010 |
Effective January 1, 2010, Medicare no longer pays the for consults.
I am sure that all of you are fully aware of this problematic fact. This article will provide you with our recommendations as to how you should bill Medicare and private payers based on the new changes.
First, let me provide a little background information. As you are well aware, Medicare has always been concerned about payments for consults and the potential for abuse. The administrators of the Medicare program, including the OIG (Office of Inspector General), review the administration of all government activities, including Medicare.
The rules have changed many times to narrow down the payment to precisely the definition of consults as determined by the government. This has been unfortunate and, in their mind, unsuccessful. In the discussion on “why they have decided to discontinue paying for consults”, they blamed the confusion on physicians, when in reality, they created the problem. Had they stuck with the original Medicare definition of a consult (and the extra payment attached to it when the new program was implemented in 1992), there would have been no confusion. Basically, in the original relative value schedule, $30 was added to each comparable indium code to pay the consultant for the estimated cost of writing a letter back to the referring physician. This should have been very simple. However, Medicare began trying to wordsmith, dissect, and limit payment due to their desire to save money. This created the problem and the issue. I was somewhat distressed to hear that they blamed the confusion on the interpretation by the physicians.
Nevertheless, regardless of the reason the new rules were implemented, we have a big problem. There are some issues that have not been resolved to which there is no good answer. However, there are areas in which the reimbursement for our services is going to be significantly reduced, and there are also other areas in which there will be administrative difficulties. We will go through each setting and give you the best advice we can on how to bill based on the changes.
First and foremost, the rules apply only to Medicare. Private payers will make their own decision as to how they will pay for consults after January 1st. Therefore, we will discuss the charging for consults for Medicare and for private payers separately.
Medicare
Medicare as “primary” insurance:
Use Medicare rules for both the primary payer (Medicare) and the secondary payer. Private payer as primary and Medicare as secondary:
Medicare has issued a new transmittal which indicates that you have two choices:
1. Bill the private payer the appropriate consult code and then change the code to the comparable E/M code and report the amount paid by private payer. Medicare will determine the additional amount they should pay based on their fee schedule for that code.
2. Bill the private payer the appropriate Medicare acceptable code and then bill the same code to Medicare.
If it is not an administrative nightmare, we recommend that you bill according to option #1 above.
Specific Medicare Billing Instructions:
Do not charge for inpatient or outpatient consults. You should use the following recommended code sets:
A. Emergency room -- use emergency room codes (99281 -- 99288) for all visits. This includes ER visits in which the emergency room physician has also charged the emergency room codes.
B. Inpatient visit -- use initial hospital visit codes (99221 -- 99223). There is one unresolved problem with this category of codes -- the 99221, the lowest level code in this category, requires at least a detailed history and physical examination. If these requirements are not met, we recommend at this time that you use an appropriate level subsequent hospital visit code. We will keep you posted on any more definitive recommendations.
C. Outpatient visit -- use new patient codes (99201-99205) for all patients in which there has been no face-to-face visit / charge for the past three years. Use established patient codes (99211-99215) for all other patients including patients referred for a new problem.
Specific Private Payer Billing Instructions:
Continue to bill all consult codes as you have in the past unless the payer specifically states otherwise.
CPT has clarified that the consult code should be used for all visits in which the decision for care of a patient is made. Keep in mind that all Medicare Advantage patients (Medicare Part C, Medicare HMOs, etc.) are private payers. These patients are not considered to be Medicare patients, and you are not required to use Medicare rules. However, we have received word that United healthcare will follow Medicare rules on all of its Medicare advantage plans such as SecureHorizons®, AARP®, edicareComplete®, Evercare®, and AmeriChoice®.
We are monitoring all payers closely and will update the information on this site as we determine how other payers are paying for consults.
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Benchmarks
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Compensation for Urologists by Practice Type |
Urologists Overall
Mean: $399,385
25th Percentile: $277,988
Median: $357,605
75th Percentile: $473,054
90th Percentile: $612,171
Urologists in a Single Specialty Group
Mean: $403,420
25th Percentile: $260,331
Median: $361,784
75th Percentile: $504,671
90th Percentile: $637,724
Urologists in a Multi-specialty Group
Mean: $396,891
25th Percentile: $286,934
Median: $357,069
75th Percentile: $449,124
90th Percentile: $592,477
Source: Physician Compensation and Production Survey 2007 Report based on 2006 Data, Extracted from Table 113A: Compensation, pg. 242
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Urology Practice Today News
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Urology Practice Enhancement Tour |
PRS is going on the road and coming to a location near you. Our nine month tour will visit 25 cities around the US.
We will offer billing and coding and practice enhancements workshops.
Learn how you can:
- Grow your practice
- Improve procedural billing
- Increase E/M accuracy
The programs also include new technology, drug innovations and in-office procedures.
The programs were developed by and presented for urologists by Dr. Ray Painter and Mark Painter.
Cost:
Day 1: $149
Advanced Procedural Billing & Coding
Friday 1:30 - 4:30 pm
For coders, billers, office managers and physicians. Followed by Exhibitor Reception 4:30 - 5:30 pm
Day 2:
$149
Breakfast Talk - Profit Centers for Urologists
Saturday, 7:30 - 8:30 am
Visit with Exhibitors 8:30 - 9:00 am
E/M Documentation and Billing for Urologists and Physician Extenders
Saturday, 9:00 am - Noon
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