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Why Neurologists and Other Specialists Oppose a CMS Proposal to Eliminate Consultation Codesa


doi: 10.1097/01.NT.0000363233.20200.80
Policy Watch

Fearing that change will cause more problems than it will solve, neurologists and other medical specialists are opposing a Centers for Medicare & Medicaid Services (CMS) proposal to eliminate consultation codes.

Beginning Jan. 1, CMS wants physicians to replace consultation codes with new or established office visits, initial hospital visits, or initial nursing facility visits.

Although CMS is not trying to save money through this change — indeed, it proposes to increase pay rates for new and established office visits by approximately 6 percent and for initial hospital and facility visits by about 2 percent — some specialists think the new policy will change the way they schedule patients, decrease communication with primary care physicians, and reduce revenues.

“Eliminating these codes will change the paradigm of how many neurologists have built their practice and their relationships with physicians who refer patients to them,” said Bruce H. Cohen, MD, a neuro-oncologist and pediatric neurologist at the Cleveland Clinic. “It is not reasonable to expect these doctors to provide the same level of service, specifically the written communication and follow-up care post-visit, when reimbursement will be reduced for every given level of service.”



In its proposed physician fee schedule for 2010, CMS recited years of confusion over consultation codes, most of which was attributed to disparities between CMS rules and the American Medical Association's Current Procedural Terminology manual.

A 2006 study by the Office of the Inspector General found that about 75 percent of services paid as consultations in 2001 did not meet all of the CMS requirements, prompting the government to overpay physicians by an estimated $1.1 billion.

CMS calls its proposal budget-neutral, that is, it does not expect it to either increase or decrease its payout to physicians. But elimination of consultation codes, along with two other proposals in the 2010 fee schedule, would redistribute CMS payments from some categories of physicians to others.

“Taken together, (the proposed rule changes) would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent,” CMS said in a press release.

The AAN Professional Association (AANPA), along with many other medical organizations, has asked CMS to drop its consultation-code proposal when the final rule is issued in November. In an Aug. 31 letter to CMS, AANPA President Robert C. Griggs, MD, wrote that the net impact for most neurologists would be negative.

“As a specialty that is already struggling with the low reimbursement for time spent evaluating and managing patients, neurology would be keenly impacted by a coding change that would create additional disincentives to spending the necessary time to talk to patients, take a thorough history, and provide patient-centered care,” the letter said.

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Marc Raphaelson, MD, a private practitioner in northern Virginia and Bethesda, MD, who represents the Academy on the AMA Relative Value Update Committee, said he was surprised and disappointed by the CMS proposal.

Although the documentation requirements for office visits and consultations have become more similar over time, the idea that the two services are roughly equivalent oversimplifies the matter, he said.

“First of all, there is a difference in the patient who sees a primary care doctor for headache, and the patient who sees a neurologist for headache,” said Dr. Raphaelson. The reasons patients visit neurologists usually are more complex.

In addition, the higher compensation for consultations reflects the longer total time required — including the patient visit and pre- and post-visit tasks — as documented by AMA surveys that CMS has traditionally relied on to determine the relative value of services.

“Medicare has the data in hand, which has been agreed upon by all the specialty societies performing consultations, that indicate that it takes about 20 minutes longer to do a consultation than a new patient visit,” Dr. Raphaelson said. “That's the biggest reason for the difference in payment. To ignore that and pretend that the only difference is the price of a stamp (to mail the consult letter) is either careless or punitive.”

The proposed rule bothers Dr. Cohen in two specific ways. First, it does not address the traditional consultation responsibility of sending a consult letter to the referring physician, which may prompt some specialists to forgo that communication.

Additionally, it offers no office visit coding option that corresponds to the highest level of consultation.

“It eliminates the possibility of a level 5 consultation, which we use for very complex patients. The new rule would result in neurologists not being reimbursed for the added time necessary to assess these patients,” he said.

Mary H. McDermott, MBA, CPC, director of the Office of Billing Quality Assurance at Johns Hopkins University School of Medicine, agrees with CMS that the consultation codes as they are currently used is a problem. She does not think the proposed fix is the solution.

A better idea, she says, is for neurologists to familiarize themselves with their local Medicare carrier's consultation rules, to understand exactly how that carrier interprets CMS rules for consultation codes, as the standards may vary from carrier to carrier.

“If we make sure all neurologists know what is expected of them by their carriers when they are billing consults, that will go a long way in resolving the issue of the error rate that Medicare seems to feel is unacceptably high,” said McDermott, who serves on the Academy's Coding Subcommittee. “By the same token, CMS must do more to ensure standards for review of consults is fair and applied equally and equitably across carriers, as this just adds to the confusion for providers who bill for these services.”

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Aside from the arguments about the validity of the proposal, Amanda Becker, the AANPA associate director of medical reimbursement, worries about the logistics associated with the proposed change.

Private payers may continue to use consultation codes, so eliminating them from the Medicare program adds another complexity to physicians' administrative burden.

“And if this is announced on Nov. 1 to be effective Jan. 1, we are very concerned about the short amount of time to educate members about how to change their coding practice,” she said.

For those reasons, some knowledgeable observers think consultation codes will survive — for a while. McDermott believes the proposed change would be even more difficult for inpatient physicians than outpatient practitioners, and that may force a delay in implementation.

“My personal feeling is that CMS is going to be hard-pressed to implement this on Jan. 1, given the amount of opposition to it, and the fact that, for physicians on the inpatient side, it's a nightmare,” she said. “That is not to say that it will not resurface at a later date once they have all of the issues worked out.”

©2009 American Academy of Neurology