A Case to Reinstate Consultation Codes

I recently had a patient who was sent to me from a frantic primary care physician. An elderly woman in her 90s had called two weeks previously with sudden-onset back pain. He had prescribed an analgesic over the phone. When the medicine proved to be ineffective, she went to the local emergency room where a $1,000 diagnosis of a urinary tract infection was made and an antibiotic prescribed. The primary care physician called pleading for an expedited consultation for the increasingly distraught patient who was unable to care for herself because of her spinal pain. I examined the elderly woman, locating the painful area over the L3 vertebra, and told her I would be able to diagnose her problem with a quick $100 radiographic test. The lumbar X-ray identified her vertebral fracture, and her dual-energy X-ray absorptiometry confirmed her osteoporosis. She received analgesics and a bisphosphonate for her osteoporosis. Within two weeks she returned with a significant decrease in her pain and improved function. In two months, she had discontinued her analgesics and had returned to living independently of her family. This story is not unique. I am sure every one of you has similar patients where your expertise offered cost-effective, quality care.

CMS and Consultation Codes

The Centers for Medicare and Medicaid Services (CMS) decided in January 2010 to eliminate consultation codes because the work performed with a consultation is not different from a new patient visit. These are not my words, but what CMS promulgated in the Federal Register. CMS contends that the only difference in work between a new patient and a consultation is a written report from the consultant. CMS misses the point. Inherent in the consultative process is the recognition that a physician with incomplete information requires the help of another physician with greater knowledge to diagnosis and treat a patient. That process requires the added work of undoing or corroborating the initial assumptions of the primary care physician. What is unconscionable is the denial by CMS of the added work associated with the consultative process and the additional remuneration associated with the elimination of consult codes.

When CMS eliminated consultation codes, they stated they would make the elimination budget neutral by re-investing the monies from the eliminated consultation codes back into evaluation and management codes. The ACR is supportive of increased reimbursement for evaluation and management services overall but not when CMS takes money for specialists and redistributes the money to primary care physicians. The result was a nominal increase in evaluation and management services. Some physicians were excited to receive an increase in the new and established codes, but most of the increase was from an indirect practice expense survey by the American Medical Association (AMA) and more than 40 specialties, including the ACR. CMS was quite crafty to increase payments for indirect practice expense at the same time they eliminated consultation codes to make some physicians believe they were actually having better revenue. Fortunately, most physicians saw through the mirage. An AMA survey reported that the elimination of consultation codes have affected physician offices. The following statistics are from that AMA survey.

• Three out of every 10 (30%) physicians 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.
• Nearly two-fifths (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’ 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.

It’s not clear that CMS really thought through the ramifications of eliminating consultation codes. By devaluing the consultation code, physicians have a disincentive to provide consults. The ACR has heard that some specialists are no longer sending reports. This is also highlighted in the AMA survey, with 6% of physicians abandoning the report back to the primary physician. I do believe that sending the report is a component of good patient care. However, I can understand the frustration of the consulting physicians who refrain from sending their written expertise when CMS claims that no extra work is performed with a consultation.

It is interesting that at least one specialty is supportive of the elimination: The American Academy of Family Physicians (AAFP). I was upset to read a recent letter to members of Congress from the AAFP supporting the elimination of consultation codes. AAFP contends that the work between a consultation code and new visit are similar. If the codes were brought back, “the policy reversal would result in the further exploitation of these codes, causing rampant billing confusion by medical practices, and ultimately result in Medicare improper and excessive payments.” It isn’t surprising that AAFP is supportive of the elimination when they received an increase in evaluation and management codes. However, I wonder if they understand that without specialists to diagnose and treat complex patients, their patients with rheumatic diseases and other specialty-related health issues will not have access to quality care.

Working for Change

The ACR has been working on this issue since we met with CMS to discuss our concerns in 2009 (Editor’s Note: Click here to read an online exclusive report on the ACR’s meeting with CMS). Our efforts have included trying to get legislative language in the healthcare reform legislation, sending letters to CMS, educating Congress, and working with many other societies. A special thanks to all the physicians, healthcare associates, and patients who visited offices at Advocates for Arthritis and helped to begin the education process. This is a complex issue, but congressional offices seem to be interested and definitely need education. The ACR will continue to edify Congress and CMS on this issue, which is a key component to the sustainability of our livelihood and our subspecialty.

In continuing our dialogue, I recently met with CMS director Donald Berwick, MD, along with Audrey Uknis, MD, ACR treasurer, and Tim Laing, MD, chair of the Government Affairs Committee. We discussed consultation codes, payment reform options, and components of quality care. We emphasized the need for recognition for the extra time required to gain the expertise resulting from fellowship training and ongoing scholarship that is needed to diagnosis complex patients that could not be cared for by primary care physicians and the reimbursement commensurate with the extra work. One of our major concerns is that if the reimbursement does not match the expertise and extra work, then physicians will stop specializing in rheumatology—which will result in access-to-care issues for the aging population. CMS has started a vicious cycle that, if not stopped, could endanger many patients from receiving cost-effective care at the appropriate time purely based on access.

I am a specialist. I am a consultant for other physicians. My skills and expertise matter. I want to be recognized for the extra training and experience I have. Other physicians send patients to me because of my specialized knowledge. They recognize my value, and patients recognize my value, but it is unfortunate that CMS does not. I am hoping that Dr. Berwick will work with the ACR and the multitude of other specialty societies to fix this lapse in judgment by CMS. Dr. Berwick believes in efficiency and quality. I believe in efficiency and quality as well. That means getting the patient to the right physician at the right time—in other words, access to quality care. In order for patients to have access to quality physicians, specialists need to be appropriately reimbursed.

Dr. Borenstein is clinical professor of medicine in the division of rheumatology at George Washington University Medical Center, in Washington, D.C., and in private practice at Arthritis and Rheumatism Associates there. Contact him via e-mail at [email protected].