Consultation CPT codes are being eliminated by Medicare starting January 1. 2010. (The link is to the federal register – the relevent section starts p 162.)
In the CY 2010 PFS proposed rule (74 FR 33551), we proposed, beginning January 1, 2010, to budget neutrally eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) by increasing the work 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 PE and malpractice RVU calculations.
Medicare claims the rulting will be budget neutral, and has balanced it with a 6% increase in RVU’s for office-based and 0.3% for in-hospital E&M services. There will be new modifiers used to identify the admitting physican and the consultants.
There’s still another 30 days to comment, though it appears pretty final to me. I’d expect managed care to follow suit.
I have mixed feelings on this one. It’s always nice to be consulted by a colleague on a challenging case, and to have this recognized by an increased reimbursement. But I know there are specialists out there who bill each and every new patient as a consult and require a referral physician name before even seeing any patient. I resent their consultant letters thanking me for referring my patient for a routine preventive service, when I never even made the referral.
One could argue that there needs to be compensation for the additional years of training and expense that specialists incur. At the same time, the imbalance in reimbursement between subspecialists and primary care has led to a shortage of primary care docs.
This ruling may be one small step towards a resolution of the primary care shortage.
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Addendum – According to this analysis, the elimination of consultation codes will save Medicare $534.5 million anually. The authors point out that the ruling “sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties.”
I'm guessing for most non-medical folks, this is confusing, as it is for me.
Did special codes for consultation mean that the consulting physician got paid more than s/he would for seeing a patient without a consult? (Does that mean, for example, that if I have a skin problem and go right off to a dermatologist, s/he gets paid less than if I ask get a referral because my family doctor needs help figuring it out?)
What does this mean for patients? Will it even out, or is this an attempt to stop some people from gaming the system in a specific way?
Bardiac –
To answer your questions – Yes. This only affects how medicare reimburses physicians, so patients should not see anything different if they are medicare participants. However, if managed care picks it up, it could mean lower costs for patients going out of network to sepcialists, but higher costs for routine care. The feds call it "budget neutral", but in the end I suspect they think it is going to save them money, meaning docs get paid less. Otherwise why would they bother?
Yes, Bardiac, that's exactly right. Docs get paid more if another doc asks them to see a patient than if the patient goes on their own. What's the difference? The point is that there shouldn't be any. I, for one, am thrilled with this development.
Patients shouldn't see any difference. Specialists (those who game the system to maximize revenue by overusing the consult codes) will see a well-deserved drop in revenue. It's a much-belated leveling of the playing field that will save money mainly by pruning bloated specialist incomes.
i cannot see a specialist [such as the dermo, when i have some skin stuff plus my dad died of metastatic skin cancer] or get followup care ordered by the consultant [such as repeat mams in 6 months because of suspicious stuff, plus my sister's breast cancer] without my primary writing a consultation order. and it has to have the right language for my insurance company.
i guess this ruling doesn't affect me since i'm not on medicare, but my system requires these orders. and they are not only a pain, but i think that means my insurance pays for the primary care order as well as the referral rate on the followup care. does that make sense? i don't do mammography or skin checks/excisions for recreational purposes.
kathy a – It will be interesting to see if the changes in consultation reimbursement are embraced by managed care, and if doing so willl affect the number of hoops you have to jump through to get to a specialist. Givent aht so much of the income from consultatns comes from procedures, I would expect the hoop jumping to continue.
I've been away from blogs for a while, but I have to say, I did 3 extra years of fellowship and I offer a lot of hard won expertise for patients. I think that that should be worth something extra. My patients are sicker than normal OB patients and I take many patients that other people won't see. I actually have medicare ob patients because some of my patients are too disabled by their dialysis/heart failure to be taken care of by another ob-gyn. So why should I get screwed? I don't bill consult fees for prenatal care for normal patients (I don't do much of that though) or pap smears (haven't done one that's not part of a new ob exam in years). I don't think I'm overcompensated..
Rheumatologists, neurologists, infectious disease, endocrinologist and psych are already paid what PCPs make. These docs dont have "bloated salaries". We are barely making it. Now we should take a cut? The non-procedural based specialties will be devastated.