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This article first appeared in RACmonitor.
Beginning on January 1, 2010, Medicare ceased the reimbursement for consultation codes (CPT codes 99241-99255), which removed 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 rule for the 2010 Physician Fee Schedule, specialty societies, most notably the American College of Cardiology, have fought for their immediate reinstatement to no avail. After over a decade of attempting to educate physicians about the documentation requirements for consultations, as well as explaining the difference between a consult and a “transfer-of-care”, Medicare has held firm with their 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 over 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 more than a year into the post-consultation world, but it struck me that with such a high error rate, the documentation for those old consultations aging in your patients’ medical records could possibly be a current or future RAC audit target. My curiosity began to run wild and it reached a wall with a simple question; can the RAC contractors 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 & 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 Apparatchik, the above paragraph is roughly translated as “Yes”.
Assessing the risks
Knowing that consultations will be on the table for RAC review until December 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 the practice to attempt to fight the RAC in the appeals process for any possible E/M reimbursement based on documentation, which is far from an enviable task.
Depending on the reliability of your practice management system, now may be as good a time as any to look at total dollars reimbursed for consultation services from February of 2008 through the end of 2009 to determine the level of financial exposure to what may become a sudden and (until now) surprising target. Remember that the number of records able to be requested by the RACs depends on the size of your practice. It is possible to assess RAC vulnerability by comparing the instances of consultations and do a rough comparison of the number of records that can be legally 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 that we exist in this current reality means that one day’s worth of consultations fall off the review table, which in turn means that the news gets better. I exist in a world of optimism that genuinely hopes that our current world continues through to the end of 2012, thereby leaving your consultation documentation right where it currently is for the rest of time.
Learn more about Fi-Med Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Related articles on RACs:
Are Ongoing DME Probes Setting Table For RAC Audit?
Does Your Usage of the -25 Modifier Make You a Future RAC Target?
Physicians Doing Work of RACs, Study Seems to Indicate
This article first appeared in RACmonitor.
Beginning on January 1, 2010, Medicare ceased the reimbursement for consultation codes (CPT codes 99241-99255), which removed 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 rule for the 2010 Physician Fee Schedule, specialty societies, most notably the American College of Cardiology, have fought for their immediate reinstatement to no avail. After over a decade of attempting to educate physicians about the documentation requirements for consultations, as well as explaining the difference between a consult and a “transfer-of-care”, Medicare has held firm with their 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 over 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 more than a year into the post-consultation world, but it struck me that with such a high error rate, the documentation for those old consultations aging in your patients’ medical records could possibly be a current or future RAC audit target. My curiosity began to run wild and it reached a wall with a simple question; can the RAC contractors 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 & 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 Apparatchik, the above paragraph is roughly translated as “Yes”.
Assessing the risks
Knowing that consultations will be on the table for RAC review until December 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 the practice to attempt to fight the RAC in the appeals process for any possible E/M reimbursement based on documentation, which is far from an enviable task.
Depending on the reliability of your practice management system, now may be as good a time as any to look at total dollars reimbursed for consultation services from February of 2008 through the end of 2009 to determine the level of financial exposure to what may become a sudden and (until now) surprising target. Remember that the number of records able to be requested by the RACs depends on the size of your practice. It is possible to assess RAC vulnerability by comparing the instances of consultations and do a rough comparison of the number of records that can be legally 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 that we exist in this current reality means that one day’s worth of consultations fall off the review table, which in turn means that the news gets better. I exist in a world of optimism that genuinely hopes that our current world continues through to the end of 2012, thereby leaving your consultation documentation right where it currently is for the rest of time.
Learn more about Fi-Med Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Related articles on RACs:
Are Ongoing DME Probes Setting Table For RAC Audit?
Does Your Usage of the -25 Modifier Make You a Future RAC Target?
Physicians Doing Work of RACs, Study Seems to Indicate