Consult Codes and Medicaid Audits
By: KATHERINE A. BURKHART
July 21, 2009
Eliminating Consultation Codes – Proposed Fee Schedule Focuses on Increasing Payment for Primary Care Services
The Centers for Medicare and Medicaid Services (CMS) published the 2010 Proposed Medicare Physician Fee Schedule on July 13, 2009. One major change proposed by CMS is the elimination of payment for consultation services (CPT codes 99241-99255). A consultation is a type of service typically provided by a specialist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician. Consultations are paid at a higher rate than other evaluation and management (E/M) services. Under the proposed rule, CMS would eliminate the use of all consultation codes (except for telehealth consultation G-codes), and all physicians and nonphysician practitioners would use the same E/M codes for new and existing patients (CPT codes 99201--99215).
CMS cited its long struggle with physicians regarding the Medicare documentation requirements for consultation services as the main reason for eliminating consultation codes. According to CMS, the savings generated from the elimination of consultation services will be used to increase payment for primary care office visits. Some specialists may see substantial reductions in reimbursement as a result of this change.
CMS is currently soliciting comments on this proposal to eliminate consultation codes through August 31, 2009. If submitting a comment by regular mail, please address to:
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1413-P
P.O. Box 8013
Baltimore, MD 21244-8013
The final rule will be published sometime in November of 2009. Stay tuned for more information.
Possibility of Federal Medicaid Audits
According to a representative from the Minnesota Department of Human Services (DHS), federal authorities will begin conducting Medicaid audits with extrapolation in the fall of 2009. There has been no formal announcement of the audits by DHS. We will continue to update our website as we learn more about this important development.