KLA Healthcare Consultants
(901) 377-8727 January 2010 - 1
In This Issue
Many Payors Still Accept Consultation Codes
AI Modifier Key to Medicare Inpatient Payments
Medicare Delay in Processing 2010 Claims
Back to Basics - Billing for Prolonged Services
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Back to Basics:
Selecting the correct evaluation and management code 
 Many Private Insurors and Some Government Payor Continue Paying for Consultation   
Eventhough Medicare has delayed pay cuts until March, traditional Medicare still is not paying consultation codes after January 1, 2010.
Many private insurors and government payors, however, will still pay consulting codes.  Based on our phone calls to provider services, the following carriers still DO PAY for consulting codes:
  • Aetna
  • AmeriChoice
  • Blue Cross (including Blue Care)
  • Cigna
  • Humana
  • Most Medicaids (including Arkansas and Mississippi)
  • TriCare
  • United Healthcare
  • Windsor
Healthsprings and Secure Horizons report they will NOT pay for consultations beginning January 1. 

AI Modifier Used To Report Attending Physician Status

Medicare has formally adopted AI as the modifier to be used as an addendum to the admission code by the attending physician when the patient is admitted to the hospital.  This is a different modifier than was previously reported.
CMS has issued an MedLearn Matters Bulletin on how to bill now that consulting codes have been eliminated.  This very important bulletin may be downloaded at:
At the Chicago meeting attendees were told that without a modifier, patient records would need to be reviewed prior to payment.  Although this seems a burdensome requirement on CMS that will likely not materialize, it may.  Therefore, specialists should be very sure that the attending physicians that refer to them are aware of the need to use the AI modifier.
Be certain that your billing staff knows when you are consulting and when you are attending so that they may appropriately use the modifier.
If you do not know the insurance of the patient, provide your billing staff with alternate coding for admissions v. consultations.  The levels of service are not a direct crossover. 
For example, a level 3 admission code (99223) typically takes 70 minutes and requires a comprehensive history and exam and medical decision making of high complexity.  A level 3 consultation code (99253) typically takes 55 minutes and requires only a detailed history and examination and medical decision making of low complexity.
Since you are ultimately liable for the level of service you bill, this is a decision best made by you.
Be sure your documentation supports the levels for which you bill.
Delay In Processing Medicare Claims for 2010 Dates of Service

CMS has instructed its contractors to hold claims for services paid under the Medicare Physician Fee Schedule for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service.

The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010.  Please note that most contractors are closed for the Martin Luther King Day holiday on January 18.  Therefore most claims would not be paid any sooner than January 19, 2010 despite the delay in processing.
Claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.
Back to Basics:  Billing for Prolonged Services
Frequently overlooked, Prolonged Services codes are available when you spend significantly longer with the patient than is normally required based on the history, physical and decision making portion of the exam. 
Prolonged Services are ADD-ON codes that result in additional reimbursement when an evaluation and management service lasts significantly longer than normal.
IT IS IMPERATIVE TO DOCUMENT THE LENGTH OF TIME YOU HAVE DIRECT FACE-TO-FACE CONTACT WITH THE PATIENT in order to use these codes.  Getting in the habit of documenting the beginning and ending times of an encounter will go far in satisfying the time based nature of the prolonged services code.
Per CPT, "Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated evaluation and management service at any level and any other physician services provided at the same session as evaluation and management services...even if the time spent by the physician on that date is not continuous."
CMS has published a MedLearn Matters Bulletin on how to appropriately use the prolonged services codes.  The Bulletin includes a very helpful chart that shows the time requirements necessary to bill prolonged services.  This bulletin may be found at:
Remember unless counseling and coordination of care dominate the encounter, the level of service is determined based on:
      1. History
      2. Examination
      3. Medical decision making
(or 2 of the 3 for established patients).
Only after the decision is made as to the appropriate level of service based on the components can you make a decision as to whether or not it is appropriate to also bill for prolonged care.