CMS Eliminates Consultations for Medicare

The Federal Register, Vol. 74, No. 226 posted November 25, 2009, contains CMS’ final decision to eliminate both outpatient consultations (99241 – 99245) and inpatient consultations (99251 – 99255) for payment purposes. CMS cites lack of understanding and confusion over their use as the rationale to eliminate them. Physicians should use either evaluation and management (992xx) or ophthalmology (920xx) codes in place of outpatient consultations.

Hospital care codes (99221 – 99223) or ophthalmology codes replace inpatient consultation codes for Medicare beneficiaries. Of particular note for inpatient services is the recommendation to use the initial hospital care codes. The Federal Register reports the following:

“Because of an existing CPT coding rule and current Medicare payment policy regarding the admitting physician, we will create a modifier to identify the admitting physician of record for hospital inpatient and nursing facility admissions. For operational purposes, this modifier will distinguish the admitting physician of record who oversees the patient’s care from other physicians who may be furnishing specialty care. The admitting physician of record will be required to append the specific modifier to the initial hospital care or initial nursing facility care code which will identify him or her as the admitting physician of record who is overseeing the patient’s care. Subsequent care visits by all physicians and qualified NPPs will be reported as subsequent hospital care codes and subsequent nursing facility care codes.”

Physicians should carefully review the documentation requirements for the hospital codes as they are difficult to satisfy for most ophthalmic visits with an inpatient.

We expect commercial payers to reconsider how they pay for consultations but not immediately follow CMS’ lead.