October 26, 2016
3 min read

Spine practices may lose money when they do not bill for consults

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In this Spine Coding Source column, Teri Romano, RN, MBA, CPC, CMDP, and Kim Pollock, RN, MBA, CPC, CMDP, combine coding pearls with information related to billing and revenue collection. It is important for health care providers to be aware of coding changes and to differentiate whether they apply to government or private payers or both.

Daniel Refai

Daniel Refai, MD

Associate Editor, Neurosurgery

Medicare eliminated payment for consultations in 2010, which resulted in significant revenue losses for spine surgeons and all specialists. All office consultations for Medicare patients became a new or established patient, or an emergency department visit if the patient was seen in the emergency department, which is an outpatient facility.

Teri Romano

Due to this change, payment for these visits was reduced 20% or more. Inpatient consult revenue for Medicare patients was also lost. For inpatients, this meant spine surgeons must code an initial hospital care code or a subsequent hospital care code in lieu of an inpatient consultation code, depending on the circumstances.

Revenue loss

Revenue loss is not the only upshot of this Medicare payment change. It also made choosing a category of code (new, established, consultation, initial hospital care, etc.) increasingly complex. This added complexity has delayed claim submission and increased denials.

Kim Pollock

To worsen the situation, many practices believed this payment change applied to all payers: private and government. This is not true. Private payers are not obligated to adopt Medicare payment policies, although many of them followed Medicare’s lead in this payer cost-saving move.

A surgical client of ours, after being advised consults could be billed to some private payers, reported an additional $4,600 in revenue in just 2 months. That represented a potential for added annual revenue of almost $28,000. If one or more of private payers continues to reimburse your practice for consultations, billing a consultation code may be appropriate in some instances. Here are examples of this for non-Medicare patients:

  • l The spine specialist sees a patient with back pain whose primary care physician asked him or her to see you — a spine surgeon — for back pain and imaging that is suggestive of a herniated disc. For this, you can code an outpatient consultation code, 99241-99245;
  • l Such billing is also possible when the spine specialist is called by the emergency department (ED) physician to the ED to see a patient with a vertebral fracture after a fall; and
  • l Billing a consultation code is possible when a hospitalist asks you to see an inpatient found to have a pathological vertebral fracture.
  • Steps to take

    A few steps can be taken to avoid losing consultations as a source of practice income.

    Start by identifying non-Medicare payers in your network or area who continue to pay for consults. Blue Cross Blue Shield, for one, is likely to still have consultations on its fee schedule and payable, if the consultation is documented and billed appropriately. Some Medicaid carriers also still recognize the consultation codes.

    Another step is to review the Current Procedural Terminology rules for consultation coding and ensure your practice follows the guidelines for reporting outpatient and inpatient consultations. Because consult codes pay more, payers will be on alert for a high percentage of consults and/or a high percentage of consults billed as level 4 or 5.

    Physicians should continue to indicate a consult on paper or electronic medical record encounter record for appropriate patients and ensure the consultation documentation rules are followed, regardless of the payer. This means documenting the request for the consult and sending a separate consultation report, that is personalized for the patient, to the requesting physician.

    It may be helpful to develop a process to capture consultation charges. This should involve making sure claims are not submitted until a coder/biller or other staff person reviews the encounter and, based on the payer, determines the appropriate category of code. It is not realistic to expect the provider to be aware of each individual patient’s payer status. This is a staff responsibility. For practices that do not currently report consultation codes, it is worth the effort to hold claims until this review is completed due to the possibility of increased revenue.

    Disclosures: Romano and Pollock report no relevant financial disclosures.