Within CPT, Modifier-51 is designed to trigger multiple procedure payment reductions when a physician performs separate procedures on the same patient during the same session. These separate procedures are not incidental to the primary procedure and are separately payable. The payer typically reimburses the highest-ranked procedure at 100 percent and any additional procedures at 50 percent. The vast majority of surgical procedure codes within CPT are subject to this multiple procedure payment reduction, the rationale being that some of the work of the procedure – specifically work performed before and after the procedure itself – is not repeated when two or more procedures are performed simultaneously.

To date, Medicare payment rates for catheterization, EP studies and ablation procedures are based on each service being provided independently. As a result, they have been exempt from Modifier-51. As of January 1, 2008, this exempt status has been revoked. From a payment perspective, the rationale is that some of the work for a given procedure is not repeated when two or more procedures are performed simultaneously.

There is no question that this policy change will negatively impact on the revenue an interventional cardiologist has been traditionally able to rely upon. However, this may not be the focus of attention when the interventional cardiologist is being looked at by Medicare. As Cardiology is largely a referral based practice, the interventional cardiologist mainly relies upon other health care providers to refer patients to the practice. Traditionally, this has produced a consultation evaluation and management code. The use of consultation codes has experienced a clarification that requires the Cardiologist to change aspects of the medical record generated as a result of the encounter as well as the potential evaluation and management CPT codes used to describe the visit.

Medicare will append the 51 modifier to secondary interventions performed and adjust reimbursement. As such, the medical record and the coding of the encounter will require very little adjustments as a consequence of this rule when a claim is submitted to Medicare. Other carriers will compel the reporting of CPT code to have the 51 modifier appending to secondary interventions. The absence of a 51 modifier will likely produce a denial of payment. Consultation codes will require considerably more manipulation to both the reporting of evaluation and management codes as well as to the medical record. The clarification to consultation evaluation and management codes allows only and encounter that does not include or imply a transfer of care to be reported as a consultation.

In the past, this transfer was generally understood to mean that the care of the patient was being transferred in its entirety to the consulting physician. The clarification now identifies transfer of care as including the transfer of a specific problem, such as angina or ECG changes, to the Cardiologist. In the absence of specific documentation identifying the visit as a request for an opinion, transfer of care is at risk for being assumed by Medicare. Consultation codes require a unique set of documentation that now must include that a transfer of care is not taking place.

Consultation codes are divided between inpatient and outpatient code sets. The inpatient codes range from 99251 to 99255. The elevation codes range from 99241 to 99245. The consultation is a type of service provided by a Physician whose opinions or advice regarding the evaluation and management of the specific problem is requested by another Physician or other appropriate sorts. A consultation requires referral from another identifiable provider. This would be a provider with a legacy UPIN number and an NPI number. It is expected that there will be a formal request from the referring provider. This can come in the form of a written order for requests as well as a telephone request. In either case, the documentation should identify the referring physicians and the reason for the request. The next requirement is for a rendering of the opinion. This portion of the documentation guidelines are for the consulting physician’s evaluation. Finally, the impression and treatment options are to be communicated back to the referring Physicians. This constitutes three R’s of the consultation process –request for an opinion, rendering of the opinion and finally the reporting of the opinion.

The consulting Physician may initiate diagnostic or therapeutic services during the visit or any anytime subsequent to the visit. If the consultation initiated by a patient or family member and not requested by a physician, or otherwise identifiable provider, it is not reported using consultation codes. This encounter would be reported using the codes for office visits or established inpatient visits as appropriate. The consulting Physician may assume responsibility for management of a portion for all of the patient’s condition subsequent to the completion of a consultation. If the referral is a transfer of care of all or a portion of the patient’s condition it should not be reported as a consultation.

The clarifications for consultation codes have the potential for negatively impacting the practice of interventional cardiology. They will require changes in the documentation of the initial, referred encounter as well as careful evaluation of the record to assure that the evaluation and management CPT used to report the visit is appropriate.