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All you need to know about Medicare Consultation codes!

Did you know how important consultation codes are? Medicare and other insurance companies have eliminated the use of consult codes. Instead, other existing codes are to be applied. The Government made certain changes in order to avoid confusion between consult codes. A glimpse of other codes is also very complex and makes billing more complicated.

The services which are prolonged should add the codes in few cases as advised by the Government. When in Neurology billing services, healthcare professionals must understand the new updated rules and code accurately with perfect patient care.

A decade earlier, the federal Center for Medicare and Medicaid Services (CMS) has allowed the use of consultation Evaluation and Management (E/M) codes especially for Medicare patients. It caused more difficulty for neurology healthcare professionals as it brings both coding as well as revenue problems.

Why Medicare consultation codes are removed?

  • CMS thoroughly without any hesitation had already responded clearly to the problems occurred due to consult codes.
  • Healthcare professionals of neurology often failed to follow the rules of CMS for consult codes.
  • CMS had mentioned the reason that, many services coded as Consult have not been coded as consultations; instead they were new or established patient services.
  • An Office of Inspector General Survey revealed that almost 75% of codes for services are mentioned as consults and failed to meet all the rules for CMS consultation services.
  • That particular coding rule has been counted within Medicare and also other insurance companies.
  • Most of the contracts along with managed care organizations and health insurance companies very neatly specify the use of Medicare guidelines as well as payment schedules based on different payment factors and rates.
  • Many encouraged Medicare to not allow consultation codes and they followed the same pattern. Whereas Medicaid is yet to follow the above rule in future.
  • Now, the above no consult code rule also applies at present to neurology healthcare professional’s case mix.
  • Eventually CMS had also increased payments for new and established patient codes. According to their plan, discontinued consult plan must be budget neutral and should not affect their economy.
  • The savings occurred due to use of lower paid codes must be equally balanced by increasing payments for those lower codes simultaneously.
  • Medicare also published and expressed interest in projecting crosswalk from consults to other codes and assumptions in budget to always keep the budget neutral.
  • Additionally, Medicare also increased both office and impatient codes by 4%-6%.
  • Medicare revenue for neurology healthcare professionals will increase when their medical practice is mainly established in office with patients and some consultations.
  • Those neurology healthcare professionals will witness Medicare payments decreasing gradually.
  • American Academy of Neurology actually has not accepted the following changes. So as many medical associations.

The New Coding Rules for Medicare:

  • Basically consultation is nothing but a reference from one physician for an opinion to another physician.
  • It consists of two broad groups CPT; E/M services codes for both inpatients and outpatients.
  • Instead of Consult codes, CMS directs healthcare professionals to crosswalk the service to Office New or Office Established, and Initial Hospital Care families of codes.
  • It resulted in many substantial organization issues after that directive.
  • For inpatients:

  1. Firstly CMS decides to crosswalk inpatient consult codes to initial hospital visit codes. The initial hospital visits codes are nothing but the same codes used by the primary attending on the day of service.
  2. Just in the case to identify the primary attending healthcare professionals for your primary day of service, Medicare advices to use Modifiers while coding their admission note.
  3. The same rules are applied for consultation in nursing homes or nursing facilities.
  • For Outpatients:

  1. The outpatient crosswalk rule is complicated as well. CMS directed neurology healthcare professionals to use the New Or Established office code, families instead of consultation codes.
  2. The New Office Visit code especially uses similar level of required documentation and services as initiated in the consult code family.
  3. Patients in the past two to three years, an established office visit code are used in lieu of consult codes. For established patients required documents are of fewer burdens.
  4. A new office visit is determined based on established office visit by face to face or interactive services that happened some three years back.
  5. E/M and EMG are face to face. EEG isn’t face to face and it also doesn’t make patient fall under established to the practice.
  • Taxonomy rule and practice groups:

  1. Not that easy to find or figure out the healthcare professional who has been seen in practice face to face for almost three years back.
  2. This three year rule applies only to services provided by healthcare professionals from the same practice group also from the same taxonomic specialty.
  3. Child neurology is not applicable officially to this particular taxonomy. There are separate taxonomic codes in Medicare mentioned for clinical neurophysiology, pain medicine, and neuromuscular medicine.
  4. It applies to the particular neurology healthcare professional listed on the primary specialty in the healthcare provider’s application.
  5. Identifying those patients who were seen face to face in the past three years also involves an organized method for inquiring the practice’s billing system, most preferably before the visit.

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All you need to know about Medicare Consultation codes!


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