$100 Down the Drain

I'd argue that I received excellent training in residency. But in retrospect, my lack of exposure to the "Medicine Consult," proved quite the deficiency.

Prior to receiving my Hospitalist Hat, the only time I ever billed a consultation was in the outpatient setting for pre-op clearance. As a clinic slave, it was an unexpected little treat. I typically got 3.02-3.77 RVUs for relatively-brainless work, compared to the 1.42 RVUs for the 40-minute octogenarian diabetic time-suck. But as an inpatient guy (in a hospitalist program without the resources to do outpatient pre-ops), a "consult" to me now typically means:

1. A surgeon who doesn't want to fill out discharge paperwork (the 75-year old with controlled hypertension who has been on a sprinkle of HCTZ for 50 years, but is in for a ureteral stent).

2. A subspecialist (still listed on the ACPs website as Board Certified in Internal Medicine) who doesn't want to be bothered with things like diabetes when there are highly billable procedures to be done.

3. Either of the above who realizes that they suck at something I can do better.

In any event, it really doesn't bother me. Because it's better for the patient. And for a small portion of my day, I get to feel special. "Of course you can't take them to surgery silly. You'll kill them."

And even though it's (for the most part) easy work, it's the work no one else wants to do even if they have the know-how. For the most part, internists have been willing to play along. After all, it pays pretty well. Consider:

LEVEL 2 ADMISSION = 2.56 LEVEL 3 CONSULTATION = 2.27
LEVEL 3 ADMISSION = 3.78 LEVEL 4 CONSULTATION = 3.29
LEVEL 5 CONSULTATION = 4.00

Now let's say the consult is full-on legit (new-onset CHF). My notes for such a scenario would typically qualify for an H&P III or a Consult III. At our $50/RVU, that equals $189.00 or $200.00. Not an enormous difference... but here's the rub.

This Medicare Coding class I just attended has informed me of a new change for 2008 that will start being enforced at some nebulous point between January 1, 2009 and Summer 2009. It's called Transfer of Care.

To illustrate the massive screw-job CMS has crafted for us, Dear Reader, consider the following scenario.

An otherwise healthy 56 year old is admitted with chest pain to the cardiology service on January 1st. Their initial troponin was 3, which is why they were not admitted to medicine. But their random glucose is 430, creatinine is 3 and their sodium is 118. Medicine is consulted.

The hospitalist dutifully comes to save the day, orders appropriate diagnostic work-up and initiates appropriate treatment. Now, I don't know about most of you, but we typically round on these patients daily. We manage the newly-diagnosed DM, the hypernatremia, and the acute renal failure. Perhaps we will involve other consultants. But we follow them to discharge and reconcile their new medication library. The patient goes home January 7th.

A lot of people out there bill something as follows (presuming appropriate complexity of care):

1/1/08: 99255 (initial inpatient consultation)
1/2/08: 99233 (subsequent inpatient care)
1/3/08: 99233 (subsequent inpatient care)
1/4/08: 99232 (subsequent inpatient care)
1/5/08: 99233 (subsequent inpatient care)
1/6/08: 99232 (subsequent inpatient care)
1/7/08: 99232 (subsequent inpatient care) -- keep in mind, we don't do the discharge here

But this would be fraud under the new rules. Because in Medicare's mind, if you are actively managing the medical conditions which you were consulted for, this is considered a Transfer of Care. And that means the highest level of care you can bill for your first note is? Are you ready? Can you wait for it?

99233 = 2.0 RVU = $100.00 (in my world)

That's right. I almost fell out of my chair. I wouldn't have believed it had my hospital not handsomely paid this consultant service to tell me this.

So instead of billing a 99255 (for $192.00), I get $100 for my 99233. Unless I squeak in prolonged services codes (which would be hard to justify in most cases), that is all Medicare tells us it's worth to start from scratch with a broken patient and fix them.

So how do you preserve the consultation code? You have to document the following:

1. That another provider has requested an advice, opinion, recommendation, suggestion, evaluation, direction or counsel concerning the patient problem or treatment options. (Caveat: the consultant is allowed to initiate treatment during the first consult.)
2. A report with the advice must be sent by the receiving provider to the requesting provider.
3. Make it clear that you are walking away from the patient.

The premise here (and it's not entirely without merit) is that the physicians requesting your opinion should be able to handle the diabetes, the hypertension, the pre-renal azotemia, as long as we give them a small refresher course in the form of a consult. They did, after all, go to medical school as well. Some of them are even Board Certified in Internal Medicine.

So what is this going to mean? I suspect there will be more snipping between internist and subspecialists. Now, these rules also apply to the subspecialist. But really... who cares about the difference between a daily note and a consult when you're performing your interventional cardiac cath? Or endoscopy? It's but a piss in the wind for those guys. But for some internists (thankfully not our hospitalist group), it's lifeblood. And suddenly the $100 dollars you lost by reclassification of your note as a "Transfer of Care" adds up.

I suspected that Medicare would focus some sniperfire on hospitalists before long. I just didn't think it was going to happen with such alacrity.