- Email: [email protected]
Medicaid Consultations
JNP
N EW D IRECTIVES Underlying
Medicare/Medicaid Consultations What defines a consultation? Effective January 1, 2006, the Center for Medicare and Medicaid Services (CMS) revised their consultation policy with clarifications regarding the definition of a consultation, when and by whom it may be performed, documentation requirements for the requesting clinician, when and by whom a consultation may be performed/reported, what a split/share evaluation is and subsequent management of patients after the initial consultation. Qualified nonphysician providers (NPPs) can perform consultations when requirements are met, a split/share evaluation and management service. New CPT codes were effective January 1, 2006, to use for follow-up visits and for second opinion evaluations. CPT codes 99261-99263 (hospital inpatient follow-up consultations) and CPT codes 99271-99275 (confirmatory consultations) were deleted.
Beginning January 1, 2006, in a facility setting, a second opinion consultation arranged through the attending will be reported by a physician/qualified NPP using an appropriate Initial Consultation code when the consultation requirements are met. When consultation requirements are not met, the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent Nursing Facility (NF) Care codes (99307-99310) in the NF will be reported. In the office or other outpatient setting for a second opinion evaluation, a physician/qualified NPP will use new patient codes (99201-99205) for new patients and established patient codes (9921299215) for an established patient as needed. • A consultation requires a request from an appropriate source, the consultation evaluation service, and a written report. • A consultation service may be based on time when the counseling/coordination of care
DECODING CODES Jan DiSantostefano 336
The Journal for Nurse Practitioners - JNP
constitutes more than 50% of the face-toface encounter. • An NPP may request or perform a consultation service within the scope of practice and licensure requirements for the NPP in the state where he or she practices and the requirements for physician collaboration and physician supervision are met. • A separate evaluation and management (E/M) code may not be billed at the same time as a consultation. • At the initial consultation service or at followup visits, both diagnostic or therapeutic services may be initiated. • Following the initial consultation service, ongoing management must be reported using the subsequent care visit codes, depending on the type of service and the setting (nursing facility, hospital, out-patient, etc). • A new patient or established patient visit code must be reported in a transfer of care situation. Initial Inpatient Consultation codes for an initial consultation in the inpatient hospital setting and the SNF/NF are 99251-99255. Appropriate Office or Other Outpatient Consultation codes for an initial outpatient consultation are 9924199245. May 2006
Follow-up visits should be coded using the following codes: • Subsequent Hospital Care codes, inpatient: 99231-99233 • Subsequent NF Care codes, in the NF setting: 99307-99310 • Office or Other Outpatient Established Patient codes: 99212-99215 Other important factors to take into consideration when billing for a consultation include the following: • CPT code 99211 does not meet the criteria for a consultation and therefore is not recognized by Medicare for a consultation service. • An initial inpatient consultation will be reported only once per consultant per patient per facility admission. • If an additional request for a consultation is received from the same or another physician or NPP (hereafter, referred to as clinician) in the office or outpatient setting, regarding the same patient, regarding the same or a new problem, and documented in the medical record, the Office or Other Outpatient codes may be used again, depending on the setting. • If the consultant continues to care for the patient for the original condition after the initial consultation, repeat consultation services should not be reported during the ongoing management of this condition. • For a second opinion evaluation requested by the patient or family in the facility arranged by the attending physician, the evaluation is reported as an Initial Consultation service if the consultation requirements are met. • If the second opinion does not meet the consultation requirements, the Subsequent Hospital Care codes for the inpatient setting and the Subsequent Care codes for the NF setting are reported. • For a second opinion evaluation, report the Office or Outpatient codes (new or established) for the office or outpatient settings. • A second opinion rendered to satisfy a requirement for a third-party payer is not a covered service in Medicare. • A written report to the attending clinician is not required by Medicare when the second opinion has been requested by the patient or family. www.npjournal.org
• Modifier –32 (mandated services) is not recognized as a payment modifier in Medicare. • Within a group practice, a consultation service will not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting. • Medicare will pay for a consultation within a group practice when the consulting clinician has expertise in a specific medical area beyond the requesting clinician’s knowledge. • A written request for a consultation should be included in the plan of care. • A consultation request may be verbal; however, there must be documentation of the verbal interaction identifying the request and reason for the consult by both the requesting clinician and the consultant clinician in the patient’s medical record. • A consultation request by the requestor may be written on a physician order form in a shared medical record. • The reason for the consultation record must be documented in the patient’s medical record by the consultant. • The consultant’s written report may be part of a common medical record or in a separate letter to the requesting clinician and readily available. • A preoperative consultation at the request of a surgeon is payable if the service is medically necessary and not routine screening. • After a preop consultation, if the same clinician assumes responsibility for management of all or part of the patient’s care postoperatively, the appropriate subsequent inpatient hospital care codes, subsequent SNF/NF codes, or established office/clinic codes should be used and not the consultation codes. • Clinicians who had been treating the patient preoperatively or who had not seen the patient for a preoperative consultation and are asked to assume management of an aspect of the patient’s care postoperatively must report subsequent hospital care codes for the inpatient setting, subsequent NF care codes in the SNF/NF setting, or the appropriate office or other outpatient visit codes in these settings. The surgeon is not asking the clinician for his or her advice or opinion on the surgeon’s care of the patient. The Journal for Nurse Practitioners - JNP
337
JNP The ICD-9-CM codes for a preoperative consultation include the following: • V72.81 Preoperative cardiovascular examination • V72.82 Preoperative respiratory examination • V72.83 Other specified preoperative examination • V72.84 Preoperative examination, unspecified The diagnosis code for which the surgery is being performed should be listed as the secondary code. Additional codes which would be pertinent for the patient’s condition should also be entered, such as hypertension, coronary artery disease, diabetes, and so forth. The complete report and examples illustrating various situations can be found at www.cms.hhs. gov/transmittals/downloads/R788cp.pdf. Jan DiSantostefano, NP, is a family and women's health nurse practitioner at the SAS Institute, Inc, in Cary, NC. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.010
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Non-Hodgkin Lymphoma: What Primary Care Professionals Need to Know Continued from Page 315 21. The non-Hodgkin’s lymphoma pathologic classification project. National Cancer Institute sponsored study of classifications of nonHodgkin’s lymphomas: summary and description of working formulation for clinical usage. Cancer. 1982;49(10):2112-2135. 22. Harris NL, Jaffe ES, Hiebold J, Flandrin G, Muller-Hermelink HK, Vardiman J. Lymphoma classification-from controversy to consensus: the REAL and WHO classification of lymphoid neoplasms. Ann Oncol. 2000;11(suppl 1):S3-S10. 23. A predictive model for aggressive non-Hodgkin’s lymphoma. The International Non-Hodgkin’s Lymphoma Prognosis Factors Project. N Engl J Med. 1993;329(14):987-994. 24. Solal-Céligny P, Roy P, Colombat P, et al. Follicular lymphoma international prognostic index. Blood. 2004;104(5):1258-1265. 25. Paryani SB, Hoppe RT, Cox RS, Colby TV, Rosenberg SA, Kaplan HS. Analysis of non-Hodgkin’s lymphomas with nodular and favorable histologies, stage I and II. Cancer. 1983;52(12):2300-2307. 26. Mclaughlin P, Fuller L, Redman J, et al. Stage I-II low-grade lymphomas: a prospective trial of combination chemotherapy and radiotherapy. Ann Oncol. 1991;2(suppl 2):137-140. 27. National Cancer Institute. Adult non-Hodgkin’s lymphoma treatment. 2005 September 7. Available at: www.cancer.gov/cancertopics. Accessed February 17, 2006. 28. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: non-Hodgkin’s lymphoma. Version 1. Jenkintown, PA; National Comprehensive Cancer Network, Inc; 2005. 29. McKinley EM, Gotten JA, Wilson HE, et al. Hydroxyldaunomycin (Adriamycin) combination chemotherapy in malignancy lymphoma. Cancer. 1976;38(4):1484-1493. 30. Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffused large B-cell lymphoma. N Engl J Med. 2002;346(4):235-242. 31. Boye J, Elter T, Engert A. An overview of the current clinical use of the anti-CD20 monoclonal antibody rituximab. Ann Oncol. 2003;14(4):520-535.
Yazhen Zhong, RN, ANP, AOCNP, works in the Lymphoma/Myeloma Department at MD Anderson Cancer Center,The University of Texas Health Science Center in Houston,Texas, and can be reached at [email protected]. She has no financial relationship with business or industry. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.017
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The Journal for Nurse Practitioners - JNP
May 2006
N EW D IRECTIVES Underlying
Medicare/Medicaid Consultations What defines a consultation? Effective January 1, 2006, the Center for Medicare and Medicaid Services (CMS) revised their consultation policy with clarifications regarding the definition of a consultation, when and by whom it may be performed, documentation requirements for the requesting clinician, when and by whom a consultation may be performed/reported, what a split/share evaluation is and subsequent management of patients after the initial consultation. Qualified nonphysician providers (NPPs) can perform consultations when requirements are met, a split/share evaluation and management service. New CPT codes were effective January 1, 2006, to use for follow-up visits and for second opinion evaluations. CPT codes 99261-99263 (hospital inpatient follow-up consultations) and CPT codes 99271-99275 (confirmatory consultations) were deleted.
Beginning January 1, 2006, in a facility setting, a second opinion consultation arranged through the attending will be reported by a physician/qualified NPP using an appropriate Initial Consultation code when the consultation requirements are met. When consultation requirements are not met, the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent Nursing Facility (NF) Care codes (99307-99310) in the NF will be reported. In the office or other outpatient setting for a second opinion evaluation, a physician/qualified NPP will use new patient codes (99201-99205) for new patients and established patient codes (9921299215) for an established patient as needed. • A consultation requires a request from an appropriate source, the consultation evaluation service, and a written report. • A consultation service may be based on time when the counseling/coordination of care
DECODING CODES Jan DiSantostefano 336
The Journal for Nurse Practitioners - JNP
constitutes more than 50% of the face-toface encounter. • An NPP may request or perform a consultation service within the scope of practice and licensure requirements for the NPP in the state where he or she practices and the requirements for physician collaboration and physician supervision are met. • A separate evaluation and management (E/M) code may not be billed at the same time as a consultation. • At the initial consultation service or at followup visits, both diagnostic or therapeutic services may be initiated. • Following the initial consultation service, ongoing management must be reported using the subsequent care visit codes, depending on the type of service and the setting (nursing facility, hospital, out-patient, etc). • A new patient or established patient visit code must be reported in a transfer of care situation. Initial Inpatient Consultation codes for an initial consultation in the inpatient hospital setting and the SNF/NF are 99251-99255. Appropriate Office or Other Outpatient Consultation codes for an initial outpatient consultation are 9924199245. May 2006
Follow-up visits should be coded using the following codes: • Subsequent Hospital Care codes, inpatient: 99231-99233 • Subsequent NF Care codes, in the NF setting: 99307-99310 • Office or Other Outpatient Established Patient codes: 99212-99215 Other important factors to take into consideration when billing for a consultation include the following: • CPT code 99211 does not meet the criteria for a consultation and therefore is not recognized by Medicare for a consultation service. • An initial inpatient consultation will be reported only once per consultant per patient per facility admission. • If an additional request for a consultation is received from the same or another physician or NPP (hereafter, referred to as clinician) in the office or outpatient setting, regarding the same patient, regarding the same or a new problem, and documented in the medical record, the Office or Other Outpatient codes may be used again, depending on the setting. • If the consultant continues to care for the patient for the original condition after the initial consultation, repeat consultation services should not be reported during the ongoing management of this condition. • For a second opinion evaluation requested by the patient or family in the facility arranged by the attending physician, the evaluation is reported as an Initial Consultation service if the consultation requirements are met. • If the second opinion does not meet the consultation requirements, the Subsequent Hospital Care codes for the inpatient setting and the Subsequent Care codes for the NF setting are reported. • For a second opinion evaluation, report the Office or Outpatient codes (new or established) for the office or outpatient settings. • A second opinion rendered to satisfy a requirement for a third-party payer is not a covered service in Medicare. • A written report to the attending clinician is not required by Medicare when the second opinion has been requested by the patient or family. www.npjournal.org
• Modifier –32 (mandated services) is not recognized as a payment modifier in Medicare. • Within a group practice, a consultation service will not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting. • Medicare will pay for a consultation within a group practice when the consulting clinician has expertise in a specific medical area beyond the requesting clinician’s knowledge. • A written request for a consultation should be included in the plan of care. • A consultation request may be verbal; however, there must be documentation of the verbal interaction identifying the request and reason for the consult by both the requesting clinician and the consultant clinician in the patient’s medical record. • A consultation request by the requestor may be written on a physician order form in a shared medical record. • The reason for the consultation record must be documented in the patient’s medical record by the consultant. • The consultant’s written report may be part of a common medical record or in a separate letter to the requesting clinician and readily available. • A preoperative consultation at the request of a surgeon is payable if the service is medically necessary and not routine screening. • After a preop consultation, if the same clinician assumes responsibility for management of all or part of the patient’s care postoperatively, the appropriate subsequent inpatient hospital care codes, subsequent SNF/NF codes, or established office/clinic codes should be used and not the consultation codes. • Clinicians who had been treating the patient preoperatively or who had not seen the patient for a preoperative consultation and are asked to assume management of an aspect of the patient’s care postoperatively must report subsequent hospital care codes for the inpatient setting, subsequent NF care codes in the SNF/NF setting, or the appropriate office or other outpatient visit codes in these settings. The surgeon is not asking the clinician for his or her advice or opinion on the surgeon’s care of the patient. The Journal for Nurse Practitioners - JNP
337
JNP The ICD-9-CM codes for a preoperative consultation include the following: • V72.81 Preoperative cardiovascular examination • V72.82 Preoperative respiratory examination • V72.83 Other specified preoperative examination • V72.84 Preoperative examination, unspecified The diagnosis code for which the surgery is being performed should be listed as the secondary code. Additional codes which would be pertinent for the patient’s condition should also be entered, such as hypertension, coronary artery disease, diabetes, and so forth. The complete report and examples illustrating various situations can be found at www.cms.hhs. gov/transmittals/downloads/R788cp.pdf. Jan DiSantostefano, NP, is a family and women's health nurse practitioner at the SAS Institute, Inc, in Cary, NC. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.010
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Non-Hodgkin Lymphoma: What Primary Care Professionals Need to Know Continued from Page 315 21. The non-Hodgkin’s lymphoma pathologic classification project. National Cancer Institute sponsored study of classifications of nonHodgkin’s lymphomas: summary and description of working formulation for clinical usage. Cancer. 1982;49(10):2112-2135. 22. Harris NL, Jaffe ES, Hiebold J, Flandrin G, Muller-Hermelink HK, Vardiman J. Lymphoma classification-from controversy to consensus: the REAL and WHO classification of lymphoid neoplasms. Ann Oncol. 2000;11(suppl 1):S3-S10. 23. A predictive model for aggressive non-Hodgkin’s lymphoma. The International Non-Hodgkin’s Lymphoma Prognosis Factors Project. N Engl J Med. 1993;329(14):987-994. 24. Solal-Céligny P, Roy P, Colombat P, et al. Follicular lymphoma international prognostic index. Blood. 2004;104(5):1258-1265. 25. Paryani SB, Hoppe RT, Cox RS, Colby TV, Rosenberg SA, Kaplan HS. Analysis of non-Hodgkin’s lymphomas with nodular and favorable histologies, stage I and II. Cancer. 1983;52(12):2300-2307. 26. Mclaughlin P, Fuller L, Redman J, et al. Stage I-II low-grade lymphomas: a prospective trial of combination chemotherapy and radiotherapy. Ann Oncol. 1991;2(suppl 2):137-140. 27. National Cancer Institute. Adult non-Hodgkin’s lymphoma treatment. 2005 September 7. Available at: www.cancer.gov/cancertopics. Accessed February 17, 2006. 28. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: non-Hodgkin’s lymphoma. Version 1. Jenkintown, PA; National Comprehensive Cancer Network, Inc; 2005. 29. McKinley EM, Gotten JA, Wilson HE, et al. Hydroxyldaunomycin (Adriamycin) combination chemotherapy in malignancy lymphoma. Cancer. 1976;38(4):1484-1493. 30. Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffused large B-cell lymphoma. N Engl J Med. 2002;346(4):235-242. 31. Boye J, Elter T, Engert A. An overview of the current clinical use of the anti-CD20 monoclonal antibody rituximab. Ann Oncol. 2003;14(4):520-535.
Yazhen Zhong, RN, ANP, AOCNP, works in the Lymphoma/Myeloma Department at MD Anderson Cancer Center,The University of Texas Health Science Center in Houston,Texas, and can be reached at [email protected]. She has no financial relationship with business or industry. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.017
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May 2006