 |
The Wellmark Physician Advisory Committee (PAC) met on Tuesday, March 9, 2010. It was moved that the Wellmark implementation date of July 1, 2010, for phasing out consultation codes be delayed. Motion seconded and carried.
Wellmark Response to Consultation Code Motion
After extensive consideration, Wellmark decided to follow Medicare’s policy, and, effective with dates of service on or after July 1, 2010, will no longer cover consultation codes (CPT®*99241–99245, 99251–99255) for the following reasons:
- Wellmark is able to minimize the effect of the change in this consultation policy through:
- an increase in Evaluation and Management (E/M) Relative Value Units (RVUs), coupled with an increase in the Wellmark Evaluation and Management (E/M) conversion factor; and
- the use of multiple conversion factors (unlike Medicare).
In addition, Wellmark’s conversion factors for diagnostic tests and interventional or surgical procedures will be modified beginning with dates of service July 1, 2010, and after.
- Wellmark has learned through physician feedback that it is important for Wellmark to use the most current Medicare RVUs. Due to the methodology employed by Medicare to reallocate the RVUs for consultation services, it would be difficult, if not impossible, for Wellmark to continue covering consultative services while updating to the most current Medicare RVUs, without a decrease in the Wellmark E/M conversion factor
- Medicare eliminated the use of consultation codes in a budget-neutral manner by:
- increasing the physician work RVUs for new and established office visits by 6 percent to reflect the elimination of the office consultation codes;
- increasing the physician work RVUs for initial hospital and facility visits by 2 percent to reflect the elimination of the inpatient consultation codes; and
- increasing RVUs for interventional and surgical procedures with a 10-day or 90-day global period, which includes E/M services.
Therefore, if Wellmark continues its use of the most current RVUs and continues paying for consultation codes, Wellmark’s 2010 fee schedule:
-
would be overvalued by 6 percent for office E/M services.
-
would be overvalued by 2 percent for hospital E/M services.
-
would be overvalued for interventional and surgical procedures.
This would necessitate Wellmark’s use of a lower E/M conversion factor.
- Even though Medicare no longer recognizes consultation codes, the RVUs for some of the consultation codes have increased. Wellmark has estimated at our current E/M conversion factor, the new 2010 consultation RVUs would “cost” Wellmark an additional $300,000 over a 12-month period.
- There would also be a physician administrative burden if Wellmark did not follow Medicare’s lead. For claims where Medicare is the secondary payer, physicians have been given the option of either:
- billing an appropriate E/M code on the primary payer’s claim, and the same E/M code to Medicare.
- billing a consultation code on the primary payer’s claim, and an appropriate E/M code to Medicare.
For a complete guide on how to bill an E/M service instead of a consultation, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.
Note: Wellmark is aware of potential litigation regarding Medicare’s elimination of consultation services. If Medicare reverses its policy position, we will not wait until our regularly scheduled July 1 update to again recognize consultation services.
*Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are include in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a registered trademark of the American Medical Association.
|
|