End confusion about modifier -57 (and get paid for initial evaluations)

Recently I completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.

Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier-57 not modifier -25. Why? Modifier-25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure. A minor procedure is defined by Medicare––and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day on the next calendar day, append modifier -57 to the E/M service.

Key points to remember:

  • Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
  • Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
  • Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
  • Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.

 

 

 

Not billing consult codes? You are losing $$$$

In 2010, Medicare stopped recognizing consultation codes. In their discussion, they stated that they still did pay for consultations, but they used other codes to pay for them such as office visits, emergency department visits, and initial hospital services. Practices adjusted to this change, and continued to bill Medicare for services. Some groups stopped billing all consults, thinking that the private payers would follow Medicare’s lead. This was a mistake. In many States and localities, commercial payers still recognize and pay for consultations using the outpatient and inpatient consultation codes. If you are not billing consultation codes to your private payers, you are losing money.

Someone in your practice needs to verify which payers still accept consultations. I did a presentation recently to a group of surgeons and their staff members and most of the practices said that their commercial payers still accepted the consultation codes and paid for those visits. Half a dozen people in the room were billing no consult services and these people were the same state and billed the same payers as the others. Essentially, they were losing their practices money because they did not bill for consultations.

Consultations have higher work relative value units (RVUs) and higher total payments than new patient visits or established patients visits. (See the chart at the end of this article) The definition of the CPT book says the consultations may be billed for new or established patients. If the practice is reporting new patients in place of consultations, there is a small but significant decrease in RVUs and payment. But if the patient is established to the practice and the practice must report established patient visits, there is a large and significant difference in work RVUs and payment. All specialty practices need to review this.

What insurances don’t pay for consultations? Medicare fee for service, Medicare replacement plans and most managed Medicaid programs. There are still some state Medicaid programs that do pay for consults but these are fewer and fewer. Many commercial payers recognize and pay for consults—have I mentioned that?

 Let’s look at the rules regarding consults. Since Medicare no longer recognizes consults, any old Medicare guidance about consults is no longer relevant. The rules related to consults are found in the CPT book and in other CPT references. According to the CPT book , “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” This definition of a consult was amended in 2010 when Medicare stopped recognizing consults. Notice that it still requires a request from another healthcare professional.   CPT says that physician or NPP may perform a consult to “determine whether to accept responsibility for ongoing management of patients entire care for the care of the specific condition or problem.” That is, I a consult can be billed for an evaluation to determine whether to accept the character patient.

As I mentioned earlier consultations may be reported for new or established patients. The consulting clinician may initiate therapeutic treatments or order diagnostic tests and still bill a consult. A service requested by a family member is not considered a consult. A request for a consultation may be verbal or in writing and must be documented in the patient’s medical record by either of the requesting or consulting physician/NPP. A written report of course is required. Here is the CPT exact language about that. “The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. “

CPT introduced the concept of transfer of care in 2010. It’s stated that if there is a transfer of care visit is no longer a consultation. I’m going to quote the CPT description of transfer of care, and then give a few examples of instances in which there is a transfer of care and a consultation would not be billed. CPT says “Transfer of care is the process whereby a physician or other qualified health care professional who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician or other qualified health care professional who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician or other qualified health care professional transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician or other qualified health care professional who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.”

Remember that one of the first statements in the CPT book about consultations is that a physician may report a consultation to determine whether to accept the care of the patient.

Examples of transfer of care:

  • Physician is called at home by the emergency department doctor about a patient and does not need to see the patient in the ED. The physician instructs the ED doctor have the patient call the office for an appointment. This is a transfer of care, not consultation from the emergency department physician. Bill a new or established patient visit.
  • The patient is seeing an oncologist in Philadelphia and moves to Harrisburg. The Philly oncologist transfers the care to the new oncologist in Harrisburg. The physician in Harrisburg does not bill for a consultation.
  • In a single specialty group, there are only rare instances of consultations. Although physicians in a single specialty group may have different areas of expertise, transferring the patient from one physician in the group to another is rarely a consult.

One word about the word “referral.” Some coders think that if the word “referral” is used then it can’t possibly be a consult. I’m not sure what the origin of this is. Look at the CPT book’s editorial comments for the current rules related to consult. There is nothing there that differentiates between referral and consult. There is a differentiation only for transfer of care, described above.

In summary:

  • A consult requires a request from another health care professional for a new or established problem for your evaluation, assessment or opinion
  • After service is provided, a report is returned to the requesting clinician
  • Document request in the medical record
  • Transfer of care is not a consult
  • Consults are not defined as new or established

If the service does not meet the requirements of consultation, or if the payer does not recognize consultations then report the service as a new or an established patient visit in the office.

 CPT definition:

“Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the exactly same specialty and subspecialty who belongs to the same group practice within the past three years.”

CMS definition:

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Questions to ask?

  • What specialty code did you use when you enrolled in Medicare and private insurance?
  • Are all of your partners in your group the same specialty?

Have you or has one of your same specialty partners had a professional service with this patient in the past three years, in any location, for any problem?

An established patient is a patient who has been seen by you or your same specialty partner (in your group) for any problem, any location, any face-to-face service in the past three years.

  • Use for office services out of global period.
  • Whether or not the patient has a new problem is not a factor.
  • Specialty designation is key.

The reason that groups stopped billing consultations was that it was difficult to keep track of what payers paid for consults and what payers didn’t. Physicians did not want to be responsible for remembering what insurance the patient had and what category of code to select. Groups that have successfully continued to report and bill for consultations usually have the physician or NPP select a consultation code if the criteria for a consultation are met. Then, behind the scenes there are edits that stop consultation codes from being submitted if the payer doesn’t recognize consults. The staff or the system can cross walk the consultation code to the correct category of code. In the office, this is a new or established patient visit. In the hospital it is an initial hospital service or emergency department visit.

Not billing for consults? Take another look.

 

New patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99201 0.48 0.75 1.23
99202 0.93 1.43 2.1
99203 1.42 2.17 3.04
99204 2.43 3.67 4.64
99205 3.17 4.77 5.82
Established patient visits
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99211 0.18 0.26 0.56
99212 0.48 0.71 1.22
99213 0.97 1.44 2.05
99214 1.5 2.21 3.02
99215 2.11 3.13 4.07
Office/outpatient consults  
  Work RVUs Total Facility RVUs Total Non Facility RVUs
99241 0.64 0.92 1.34
99242 1.34 1.93 2.52
99243 1.88 2.7 3.45
99244 3.02 4.34 5.16
99245 3.77 5.37 6.29