PHILADELPHIA — Be careful how you code for consultations because Medicare contractors will be watching this area carefully, coding experts said at the annual meeting of the American College of Physicians.
In March, the Department of Health and Human Services Office of Inspector General (OIG) issued a report highlighting more than $1 billion in estimated overpayments made to physicians in 2001 for consultations under Medicare. In many cases, services were incorrectly billed as consultations, coded for the incorrect type or level of consultation, or were not supported by documentation, according to the OIG report.
OIG officials selected a random sample of 400 consultations allowed by Medicare during 2001, obtained photocopies of portions of patients' medical records, and hired certified professional coders to audit the claims. The results of that audit were extrapolated to produce the $1.1 billion overpayment estimate. Officials found the most problems with consultations billed at the highest billing level and with follow-up inpatient consultations, according to the OIG report.
Pay attention to the definition of and the elements involved in high-level consultation codes, advised Dr. Glenn D. Littenberg, chair of the ACP subcommittee on coding and reimbursement. He urged physicians to keep in mind that a level 5 consultation code involves an extended history of the present illness, a complete system review, a complete family social history, a comprehensive physical exam, and high-complexity decision making.
Complete documentation is essential and should include the request from the referral source, what services were provided by the physician, and the report back to the referral source, Dr. Littenberg said. “It's highly likely that based on [the OIG] report, carriers will be paying a little more attention to consultation coding at the high level,” he said.
Officials at the Centers for Medicare and Medicaid Services have already made some changes in consultation coding this year. Beginning this year, CMS has eliminated the CPT codes for follow-up inpatient consultations (99261–99263) and confirmatory consultations or second opinions (99271–99275).
In the office setting, physicians can use the office or other outpatient consultation codes (99241–99245) for initial consults and the office or other established patient codes (99212–99215) for follow-up visits.
Consultations that are requested by the family or patient instead of a physician cannot be billed using consultation codes, according to CMS, and instead physicians should rely on existing E/M codes for the setting where the service is provided.
The OIG report is available online at www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf