CMS eliminated Medicare physician fee schedule payments for consultation codes.
A "consultation" is an evaluation and management service provided by a physician (a) at the request of another physician or medical source, (b) to recommend care or provide an opinion, or to determine whether to take over management of the patient’s care, and (c) where both the request for a consultation and the resulting report must be documented in the patient’s record. Medicare has provided reimbursement for consultation codes since 1982.
In 2010, the Centers for Medicare and Medicaid Services eliminated consultation service codes citing improper coding and instructed providers to use existing visit codes. This policy change has dramatically decreased revenue for many specialists and subspecialists and is creating obstacles in patient access to essential specialty care.
Medicare reimbursement policy should recognize the value of specialty care expertise.
Physicians who perform consultations are generally specialists who—
- have completed additional training and acquired medical expertise that primary care physicians do not receive.
- have the expertise to analyze and synthesize the medical data into meaningful recommendations that are individualized to patient’s needs.
- do not have a previous relationship with the patient.
- often must complete an exhaustive clinical evaluation and review medical history of critically ill patients who often suffer from multiple chronic conditions.
Early diagnosis and specialized treatment of complex conditions is paramount to optimal patient outcomes. Patients receive improved outcomes at a lower cost when treated by an appropriate specialist.
Eliminating specialty care consultations has already reduced specialty care under Medicare.
Medical specialty groups and the American Medical Association surveyed physicians on the impact of the elimination of consultation codes. Over 5,500 physicians who completed the survey have been forced to take cost-cutting steps to offset revenue losses associated with the elimination of these codes.
- Three out of every ten (30%) have already reduced their services to Medicare patients or are contemplating cost-cutting steps that will impact care.
- One-fifth (20%) have already eliminated or reduced appointments for new Medicare patients.
- More than one-third (39%) will defer the purchase of new equipment and/or information technology.
- More than one-third (34%) are eliminating staff, including physicians in some cases.
- Following CMS’s suggestions that they no longer need to provide primary care physicians with a written report, about 6% have stopped providing these reports, while nearly another one-fifth (19%) plan to stop providing them.
Solution
We believe the CMS policy to eliminate consultation codes obstructs care coordination and will reduce quality of care for patients with complex conditions.
We respectfully urge that Congress pass legislation requesting that CMS reinstate and appropriately reimburse consultation service codes to reflect the additional training specialists receive and the expertise and high-valued care that can be provided to patients with complex conditions.
For more information, please contact ACR's Government Affairs Director, Aiken Hackett, at
