Vol. 16, Number 3
New CMS Rules May Block Billing for Initial Consultations
A new memo from Medicare implies that infectious diseases physicians may no longer be able to bill for many of their initial inpatient consultations.
According to a transmittal from the Centers for Medicare and Medicaid Services (CMS), if a consultant takes responsibility for all or part of a patient’s care, the initial visit is no longer considered a consultation and cannot be billed as such.
Rather, these initial consultative visits should be billed as subsequent hospital care codes (99231-99233). According to the CMS document, the only case in which physicians may bill initial inpatient consultation codes (99251-99255) is for one-time patient visits with no follow-up involved. The policy change was to have taken place beginning Jan. 1, 2006.
IDSA, the American MedicalAssociation, and the Association of American Medical Colleges are working together to develop language to be submitted to CMS proposing revisions to the document to reflect the current standard of care.
The current standard of care in most hospitals is for a consultant to continue to follow the patient and provide ongoing care after the initial consultation is completed, until the problem for which the consultant evaluated the patient has been resolved or stabilized to the point that his or her input is no longer necessary.
The revised language would allow an initial inpatient consultation to be billed even if there is a partial transfer of care to the consulting provider. Follow-up visits would then be billed as subsequent hospital visits.
Lawrence P. Martinelli, MD, FIDSA, is playing a key role in drafting the revised language. He said that the transfer-of-care issue is critical to IDSA members. “The CMS policy on initial inpatient consults is misguided and could have a chilling effect on cognitive specialties,” Dr. Martinelli said. He added that two-thirds of the income of ID physicians is derived from inpatient visits.
The CMS document, known as transmittal #788, also prohibits the use of split/shared consultations between a physician and a physician’s assistant or advanced practice nurse. According to the transmittal, in order for the physician to bill for the visit, he or she must do 100 percent of the work. The suggested revisions will likely include language allowing split/shared consultations as long as the consulting physician examines the patient and is directly involved in the medical decision-making. Under the proposed language, a qualified non-physician practitioner may take the patient’s history, perform an initial examination,and document the consultation in the patient’s medical history.
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