If You Aren't Billing These Codes, You're Losing Money

February 6, 2019

Medicare eliminated payment for consultations way back in 2010, resulting in significant revenue losses for surgical specialists. All office consultations for Medicare patients became new or established patient visits, with reductions in payment of more than 20% for some codes. Inpatient consultation revenue for Medicare patients was also lost.
But to make a bad situation worse, many practices believed that this payment change applied to all payors, private and Medicare. This was and is still not true. Private payors are not obligated to adopt Medicare payment policies. Although many quickly followed Medicare’s lead in the 2010 cost saving move, others continued to pay for consultation codes. And they still do.
If you’re not billing consultation codes to the private payors who reimburse for them, you should be. The resulting revenue can be significant.
After attending one of our specialty coding courses and learning that consults could indeed be billed to some private payers, one practice reported an additional $4,600 in revenue in just two months! That’s potential added annual revenue of almost $28,000.
What can you do to make sure you aren’t losing this potential practice revenue?

Here are 4 steps to take now:

Step 1: Identify private payors in your network or area who continue to pay for consults.
Step 2: Review the CPT rules for consultation coding and make sure you follow the rules of outpatient and inpatient consultations. Since consult codes pay more, payors will be on alert for a high percentage of consults and/or a high percentage of consults billed as a level 4 or 5. Be hyper-vigilant about following the guidelines.
Step 3: Continue to indicate a consult in your EHR for appropriate patients, and ensure that consultation documentation rules are followed, regardless of payor. This means sending documentation of the consultation to the requesting provider and documenting this consultation report in that visit’s record.
Step 4: Develop a process to capture consultation charges. Make sure claims are not submitted until a coder/biller or other staff person reviews the encounter and, based on the payor, determines the appropriate category of code. It’s not feasible to expect the provider to be aware of each individual patient’s payor status. This is best made a staff responsibility. Holding claims until this review is well worth the increased revenues that can be expected if you are currently not reporting consults.


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