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Beginning January 1, 2010, Medicare ceased issuing reimbursement for consultation codes (CPT codes 99241-99255), thereby removing one of the biggest areas of reimbursement for specialist physicians.

From the time this decision was brought forward by CMS as part of the proposed rules for the 2010 Physician Fee Schedule, specialty societies, most notably the American College of Cardiology, have fought to no avail for immediate reinstatement of the reimbursement. Even after more than a decade of attempting to educate physicians about the documentation requirements for consultations, and explaining the difference between a consult and a “transfer-of-care,” Medicare has held firm with its original determination.

In this cold part of the country, in the heyday of consultation reimbursement, WPS Medicare estimated at one point that the payment error rate for consultations was higher than 40 percent. It was numbers like this in the Upper Midwest and other payment jurisdictions that made Medicare’s decision to cease reimbursement that much easier.

RAC Issue

We are now 13 months into the post-consultation world, but it struck me that with such a high error rate, the documentation for those old consultations languishing in your patients’ medical records could be current or future RAC audit targets. My imagination began to run wild, ultimately reaching a wall with a simple question: can the RACs look at consultations for medical necessity review even though Medicare no longer reimburses the service?

With question in hand, and curiosity aflame, I sent this question to Scott Wakefield, the CMS project officer for recovery audit operations for RAC Regions A and B. In response, I received the following answer:

“By their statutory and contractual authorities, the CMS Recovery Audit Contractors (RACs) may review any Medicare, Fee for Service claim within a 3-year look-back period if it has been deemed that an improper payment (under or overpayment) may have been made, and the associated review issue has been approved by CMS and posted to the respective RAC Website.”

In case you haven’t mastered the mysterious dialect of government jargon, the above paragraph roughly translates to “yes.”

Assessing The Risks

Knowing that consultations will be on the table for RAC review until Dec. 31, 2012 is disheartening for two reasons. First, the documentation for these services is closed and is roughly a year too old for addenda to be included in any fashion. Second, thanks to Medicare’s new and shortened time window for claims submissions, corrected claims cannot be submitted. If the RACs decided to commence reviews of consultation services from 2009 and the bulk of 2008, it would be left up to practices to attempt to fight them via appeal for any possible E/M reimbursement based on documentation: far from an enviable task.

Depending on the reliability of your practice’s management system, now may be as good a time as any to look at total dollars reimbursed for consultation services from February 2008 through the end of 2009 to determine your level of financial exposure to what may become a sudden and surprising target. Remember that the number of records eligible to be requested by the RACs depends on the size of your practice. It is possible to assess vulnerability by comparing the instances of consultations and performing a rough comparison against the number of records that legally can be requested.

Some Good News

The only positive news that can be brought forward at this moment in time is that to date, consultations are neither an approved issue nor a RAC probe audit target for any of the contractors. Each day we exist in this current state means that one day’s worth of consultations fall off the review table, which in turn means that the news continues to get better. I exist in a world of optimism and genuinely hope that this continues through the end of 2012, thereby leaving your consultation documentation right where it currently is until the end of time.

Of course, I thought my beloved Philadelphia Eagles would finally win the Super Bowl this year, so you may want to prepare yourself just in case.

About the Author

Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.

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J. Paul Spencer, CPC, COC

J. Paul Spencer is a senior healthcare consultant for DoctorsManagement. Is the national correspondent for Monitor Mondays, the live Internet radio broadcast produced by RACmonitor.

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