Consult Code Conversions and Consequences

By  |  January 29, 2010 | 

Troy Ahlstrom writes…

As I’m sure you’re aware, CMS has eliminated consult codes for 2010.  (We’ve discussed this topic on this blog previously with Drs. Nelson and Bessler.)  Interestingly, our practice ran an analysis on the effect of changing these inpatient consultation codes (99251-55) over to new patient history and physical codes (99231-33) and found that we might actually do a bit better financially with the conversion.  Welcome findings, no doubt…

However, what about the impact on our colleagues with traditional practice models?

Unfortunately, an analysis of such codes for outpatient practices bears evidence of negative financial impact.  There’s a catch here, and it’s certainly not lost on our colleagues; any patient that they’ve seen in their office in the past 3 years for a consultation converts to an established patient visit.  They cannot convert the consultation to a new patient visit, nor can they use an inpatient history and physical code.  The table of conversions from outpatient consultations to outpatient established visits tells the story:

Outpatient Consultation Codes Converted to Outpatient Established Patient Visits
Level 1  –  $  32.69  to  $    8.89  (73% Decrease)
Level 2  –  $  68.88  to  $  24.12  (65% Decrease)
Level 3  –  $  95.85  to  $  47.54  (50% Decrease)
Level 4  –  $ 151.46 to  $  73.46  (51% Decrease)
Level 5  –  $ 189.11 to  $ 103.60  (45% Decrease)

Yikes!  That’s basically a 50% pay cut for the same work.  How many Family Practitioners or Internists can afford to take that cut on a portion of their practice these days?  Not many, I’d venture.  Furthermore, such consultation codes had represented a promising glimmer of profit to offset the numerous other cuts they’ve seen over the past five to ten years in ancillary services which paid for the staff, services, bricks, and mortar that make up an outpatient medical office budget.  I think we’re going to see a continuing shortage of physicians entering primary care practices should these trends continue.

As for Hospitalists and the quality of hospital care, I have concerns as well.  We may see a trickle-down effect of decreasing numbers of high quality pre-surgical evaluations from primary care providers.  For those of us working the floors, that means more potential perioperative complications.  It also portends resultant impacts on quality of care and increased time requirements to care for these sicker patients.  For our surgical colleagues, it means more potential for cancelled surgeries due to missed preoperative issues which could have been managed with a fuller assessment.  And that is in addition to the potential for perioperative morbidity already described.

If your practice has a preoperative clinic, get ready for the same financial cuts.  That’s outpatient work, and even if all the patients are new patients, it’s still a significant decrease in revenue to the tune of about 20%.  Moreover, it cuts both ways because the revenue decrease may well drive primary providers to send more of their outpatient consultations to these hospital affiliated preoperative clinics in lieu of other better paying visits for that busy office provider.

On the other hand, I guess this is another opportunity to provide value to the patients, providers, hospitals, and communities we serve.  Yet it still needs to be a value that allows us to have a profit margin for operations long term.  Once again, Medicare Part A will be filling in deficits in Medicare Part B to make this work, and that has been a constant drum beat that’s getting louder every day.

One Comment

  1. Brad
    Brad January 29, 2010 at 8:52 pm - Reply

    On the inpt front, my bet is reality will trump theory and not much will change.

    On outpt front, cant deny primary care is bruised and needs a reboot in the biggest way. However, see this recent Archives of IM article. Interesting. Codes were misused at a very high rate (probably not fraud, just misunderstanding of rules):

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