Instead of holiday festivities, Medicare is giving providers a lump of coal in the form of a possible 21.5% reduction in fees and elimination of consultation codes.
Medicare Eliminates Consult Codes for 2010
As of this writing, Medicare will eliminate consult codes effective January 1, 2010. This affects office, hospital and nursing home consults and applies to Medicare Advantage Plans such as Medicare Plus Blue as well as original Medicare. It also applies whether Medicare/MA is primary or SECONDARY. However, other payers may continue to pay for consults and that creates great uncertainty - and possibly financial jeopardy - for you if you bill incorrectly. Here's the dilemma you face.
If Medicare or Medicare Advantage is primary, you must bill visit codes 99201-99205 or 99212-99215 for office services or 99221-99223 for hospital services. However, if a commercial carrier is primary and Medicare is SECONDARY, you may still bill a consult but there could be a huge financial consequence if you do so without knowing how the primary payer will adjudicate your claim. Here are two scenarios:
- Commercial payer reimburses the consult without a co-pay or deductible. This is great for you because you'll receive 100% of the commercial payer fee schedule.
- Commercial payer applies a co-pay or deductible or may determine the service is not a benefit (i.e. BCBSM may not pay for office visits). If you bill the primary payer and it applies some, most or all of your charge to deductible, co-pay or non-covered service, you CANNOT bill Medicare/MA as the secondary payer. You will be stuck with whatever the primary carrier pays - and that could be nothing.