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ACRO ALERT  Payments for Consultations Eliminated as of January 1, Decline in Reimbursement to Result.
published 1/11/2010
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


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