CMS Manual System

CMS Manual System

Pub 100-04 Medicare Claims Processing

Transmittal 1875

Department of Health & Human Services (DHHS)

Centers for Medicare & Medicaid Services (CMS)

Date: December 14, 2009 Change Request 6740

SUBJECT: Revisions to Consultation Services Payment Policy

I. SUMMARY OF CHANGES: In the calendar year 2010 physician fee schedule final rule with comment period (CMS-1413-FC) CMS budget neutrally eliminated the use of all consultation codes (inpatient and office/outpatient codes) for various places of service except for telehealth consultation G-codes. CMS increased the work relative value units (RVUs) for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our practice expense PE and malpractice calculations. CMS also increased the incremental work RVUs for the evaluation and management (E/M) codes that are built into the 10-day and 90-day global surgical codes. All references (both text and code numbers) in IOM Publication 100-04 (CP), Chapter 12 ?30.6 that pertain to the use of the AMA CPT consultation codes (ranges 99241-99245 and 99251-99255) are removed by this transmittal.

NEW / REVISED MATERIAL EFFECTIVE DATE: *January 1, 2010 IMPLEMENTATION DATE: January 4, 2010

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D R R

R

R R R

Chapter / Section / Subsection / Title

12/30/30.6.1/ Selection of Level of Evaluation and Management Service

1230/30.6.8/ Payment for Hospital Observation Services (Codes 99217 99220) and Observation or Inpatient Care Services (Including Admission and Discharge Services - (Codes 99234 - 99236)

1230/30.6.9.1/ Payment for Initial Hospital Care Services (Codes 99221 99223) and Observation or Inpatient Care Services (Including Admission and Discharge Services) (Codes 99234 - 99236)

12/30/30.6.10/ Consultation Services (Code 99241 - 99255)

12/30/30.6.11/ Emergency Department Visits (Codes 99281 - 99285)

12/30/30.6.13/ Nursing Facility Services (Codes 99304 - 99318)

R

12/30/30.6.15.1/ Prolonged Services With Direct Face-to-Face Patient

Contact Service (Codes 99354 - 99357) (ZZZ codes)

III. FUNDING: SECTION A: For Fiscal Intermediaries and Carriers: No additional funding will be provided by CMS; Contractor activities are to be carried out within their operating budgets.

SECTION B: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

IV. ATTACHMENTS:

Business Requirements

Manual Instruction

*Unless otherwise specified, the effective date is the date of service.

Attachment - Business Requirements

Pub. 100-04 Transmittal: 1875 Date: December 14, 2009 Change Request: 6740

SUBJECT: Revisions to Consultation Services Payment Policy

EFFECTIVE DATE: January 1, 2010

IMPLEMENTATION DATE: January 4, 2010

I. GENERAL INFORMATION

A. Background: In the calendar year 2010 physician fee schedule final rule with comment period (CMS1413-FC) CMS budget neutrally eliminated the use of all consultation codes (inpatient and office/outpatient codes) for various places of service except for telehealth consultation G-codes. CMS increased the work relative value units (RVUs) for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our practice expense and malpractice calculations. CMS also increased the incremental work RVUs for the evaluation and management (E/M) codes that are built into the 10-day and 90-day global surgical codes. All references (both text and code numbers) in Pub 100-04 (CP), Chapter 12, ?30.6 that pertain to the use of the AMA CPT consultation codes (ranges 99241-99245 and 99251-99255) are removed by this transmittal.

B. Policy: Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting all physicians (and qualified nonphysicians where permitted) who perform an initial evaluation and management may bill the initial hospital care codes (99221 ? 99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

Modifier "-AI," defined as "Principal Physician of Record," shall be used by the admitting or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier "-AI" in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. NOTE: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. It is not necessary to reject claims that include the "-AI" modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes). Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians shall bill the available code that most appropriately describes the level of the services provided.

Method II Critical Access hospitals (CAHs) may bill on type of bill (TOB) 85X with revenue code (RC) 96X, 97X or 98X, using the appropriate new or established visit code (99201 ? 99215) for those physician and non-physician practitioners who have reassigned their billing rights, depending on the relationship status between the physician and patient.

RHCs and FQHCs shall discontinue use of AMA consultation codes 99241-99245 and 99251-99255 and should instead use 99201-99215 and 99304-99306. In the office or other outpatient setting where an evaluation is performed physicians and qualified nonphysician practitioners shall use the CPT codes (99201 ? 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.

All E/M services shall follow the E/M documentation guidelines available on . In Medicare Part B paid under the physician fee schedule, a new patient is a patient who has not received any professional services, i.e. e/m service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

II. BUSINESS REQUIREMENTS TABLE

Use"Shall" to denote a mandatory requirement

Number 6740.1 6740.2 6740.3

Requirement

Effective January 1, 2010, contractors shall no longer pay CPT consultation codes (ranges 99241-99245, and 99251-99255). NOTE: These codes are no longer recognized by Medicare with the 2010 Medicare Physician Fee Schedule (MPFS) update, since the status indicator is now an "I" (invalid for Medicare). In the outpatient CAH setting, Method II CAHs may bill on TOB 85X with RC 96X, 97X or 98X, using the appropriate new or established visit code (99201 ? 99215) for those physician and non-physician practitioners who have reassigned their billing rights to the CAH, depending on the relationship status between the physician and patient. Contractors shall take no action if the "-AI" modifier is billed with codes that fall outside of the correct range (99221-99223 and 99304-99306).

Responsibility (place an "X" in each

applicable column)

A D F C R Shared- OTH

/ M I A H System ER

B E R H Maintainers

MM AA C C

R I F MV C

I

I C MW

E SSSF

R S

X XX

IOCE

X X

X XX

III. PROVIDER EDUCATION TABLE

Number 6740.4

Requirement

A provider education article related to this instruction will be available at shortly after the CR is released. You will receive notification of the article release via the established "MLN Matters" listserv. Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. In addition, the provider education article shall be included in your next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly.

Responsibility (place an "X" in each

applicable column)

A D F C R Shared- OTH

/ M I A H System ER

B E R H Maintainers

MM AA C C

R I F MV C

I

I C MW

E SSSF

R S

X XX

6740.5 6740.6

Contractors shall employ the "MLN Matters" article to X educate all physicians and (qualified nonphysician practitioners where permitted) who perform an initial evaluation shall in the inpatient hospital setting and nursing facility setting bill an initial hospital care visit code (CPT code 99221 ? 99223) or nursing facility care visit code (CPT99304 ? 99306). Contractors shall employ the "MLN Matters" article, to X educate physicians that the physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care, shall append modifier "-AI" Principal Physician of Record, to the initial hospital or nursing home visit code when billed (CPT codes 99221 ? 99223 and 99304 ? 99306).

X X X X

6740.7

Contractors shall employ the "MLN Matters" article to X educate all physicians and qualified nonphysician practitioners to bill the appropriate new or established visit code (CPT codes 99201 ? 99205 or 99211 ? 99215), in the office and other outpatient settings, depending on the relationship status between the physician and patient.

X X

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