December 16, 2009

Dear Member:

Last week, The Endocrine Society asked you to contact Department of Health and Human Services (HHS) Secretary Kathleen Sebelius requesting a one year delay in the implementation of the Centers for Medicare and Medicaid Services (CMS) policy to eliminate Medicare billing for consultation service codes. In place of consultation codes, CMS's plan requires physicians to use already established codes for either new or established outpatient/office visits or initial hospital stays. Reimbursement for these CPT codes have been increased by 6 percent and 2 percent respectively to offset losses from the elimination of consultation code billing. This proposal is scheduled for implementation on January 4, 2010.

Yesterday, CMS released its Change Request (CR) documentation which includes detailed information on how physicians will be required to appropriately code for consultation services using outpatient/office visit and initial hospital codes. Recently, a coalition of medical specialty societies, including The Endocrine Society, secured Senator Arlyn Specter (D-PA) to introduce an amendment delaying implementation of the consultation code proposal for one year. While the Society and its coalition partners will continue to press CMS and Congress for this delay, we believe it is important to share the details included in the CR so that Society members can prepare for the implementation of this policy regardless of any last minute delays. Important details of the proposal include:

•    A new modifier, "AI," defined as "Principle Physician of Record" should be appended to initial hospital visit codes submitted by the admitting or attending physician who oversees the patient's care. This modifier will distinguish the admitting/attending physician from other physicians who may be furnishing specialty care for the same patient.

•    In the office or outpatient setting, physicians and non-physician providers (NPPs) shall follow the E/M documentation guidelines for all E/M services, which are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer. Details on documentation guidelines can be found here.

•    To bill the highest level of visit codes, the services furnished must meet the definition of the code. The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. For an established visit, the physician can review the existing record and update it to reflect only changes in the patient's medical, family, and social history from the last encounter, but the entire history must be reviewed by the physician for it to be considered a comprehensive history.

•    Physicians should select the appropriate CPT code for the service rendered based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50 percent of the face-to-face time or more than 50 percent of floor time (for inpatient services) is spent providing counseling or coordination of care.

•    For a split E/M service in the office/clinic setting, the service must be reported with the physician's UPIN/PIN if the requirements for "incident to" are met, otherwise they must be reported using the NPP's UPIN/PIN. In the hospital setting, the service may be billed under either the physician's or the NPP's UPIN/PIN.

Additional information on the implementation of these coding changes, including information on observation care and prolonged services, is available in the Change Request document and a forthcoming  MedLearn Matters article on the issue which can be found here (articles are located in the “downloads” section of the web page).

If you have additional questions, please contact Holly Whelan, Associate Director of Health Policy, at hwhelan@endo-society.org.