CMS has eliminated inpatient and outpatient consultation
code reimbursement for medical specialists, including radiation oncologists
(codes 99241-99245 and 99251-99255). Instead, radiation oncologists can bill a
new patient visit for Medicare patients. The reduction in reimbursement for us
is substantial:
CPT 99245 Level 5 Outpatient Consultation Medicare Allowable: $226.92
CPT 99205 Level 5 Outpatient New Patient Office Visit
Medicare Allowable: $148.27
CPT 99215 Level 5 Outpatient Office Visit Medicare
Allowable: $102.59
Prior to the new rules, consultations could be charged once
per year as long as all criteria were met including referral by another
physician. Currently, a new patient visit can be charged only once every three
years, regardless of the complexity of their medical care or new problems that
may have arisen. In this situation, the lower reimbursing code of Level 5
outpatient office visit may be charged, see reimbursement differences above.
Based on Florida Medicare rates, reimbursement per patient
is $78.65 less, for a reduction of 34.65% for this code. This will have a
significant effect on radiation oncologists.
The initial rationale for instituting consultation codes was
to pay specialists, with a longer time of education, more for specialized
knowledge. The rationale for eliminating payment for consultation codes was to
reroute the savings and increase reimbursement for primary care-which has not
occurred. CMS further underscored their desire to stop paying for consultation
codes by using a 2006 study done by the Office of the Inspector General that
indicated that 75% of services billed as consultations, did not meet criteria
and resulted in overpayments to physicians. This was mostly due to lack of a
ten part review of systems. The documentation requirements for 99205 are
considerable less stringent, especially with respect to review of systems and
we no longer will need proof of which physician consulted us.
Most private insurers will continue to recognize and
reimburse for consultations, however it may not be long before they also follow
Medicare's lead.
Paul J. Schilling, MD, FACRO
|
