Reimbursements to Physicians for Non-Face-to-Face Services and Consultations

The RBRVS Physician Fee Schedule regulations, effective for services on or after 1/1/14, introduced two Medicare rules that are the subject of much discussion in the workers’ compensation community.

• CCR §9789.12.8 provides the explanation for service codes that are labeled with a status indicator reflecting their bundled status under the Medicare RBRVS payment system: Codes with bundled status indicators are not separately paid because payment is included in the payment for other services:

“Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident.”

Under the previous Physician Schedule, medical providers have billed prolonged service codes and report codes for services provided before or after direct (face-to-face) patient care, such as review of extensive records, reports and other communications with professionals and family members. Under the RBRVS Physician Schedule such services are not separately payable as their payment is included in the payment for the underlying office visit or other service.

• CCR §9789.12.12 states that CPT consultation codes shall not be used. Physicians are instructed to instead bill for consultation services using the CPT Evaluation and Management (E/M) visit codes:

“Physicians and qualified non-physician practitioners shall code consultation visits as patient evaluation and management visits utilizing the CPT Evaluation and Management codes that represent where the visit occurs and that identify the complexity of the visit performed. CPT consultation codes shall not be utilized.”

In the past, physicians billed for consultation services using the CPT consultation codes and billed for the report that was generated as a result of the consultation. CCR §9785 requires secondary physicians to report to the primary treating physician who is responsible for incorporating findings of secondary physicians into the primary treating physician’s report to the claims administrator.

Although consultation reports and non-face-to-face prolonged service codes are not separately paid under the new schedule, as was noted in our March 28 Exec Memo, some physicians are demanding that claims administrators sign letters of agreement stipulating to payment for medical records review and secondary physician reports. These demand letters reflect a misconception that consultation and non-face-to-face services are no longer reimbursed under the 2014 Physician Fee Schedule. In fact, payments for these services are addressed in the increased value for E/M services. When Medicare ceased providing separate payment for consultation codes in 2010, the resulting savings were redistributed across the E/M office visit codes, increasing payments by approximately 6%. In addition, on average the 2014 Physician Fee Schedule increased the maximum reasonable payment by about 30% for these E/M codes, addressing the inclusion of non-face-to-face services, such as review of medical records, as well as the documentation of findings. While there may be circumstances where additional payment for outliers may be warranted, payment for services above maximum fee schedule allowances should be the rare exception.

The DWC created RBRVS FAQs and an RBRVS Fact Sheet to help clarify these and other recent payment changes under the RBRVS Physician Fee Schedule. To view the DWC’s RBRVS Fact Sheet and FAQs, the fee schedule regulations, and other helpful information on the RBRVS Physician Fee Schedule, click here. 

SLJ/