Anesthesia Coding Alert

Question: In our practice we have two physicians who are board-certified in pain management. May we charge a consult when outside pain management provider requests one of our physician's opinion on a specific patient?

South Carolina Subscriber

Answer: Yes, physicians of the same specialty may request consultations (99241-99245, outpatient; or 99251-99255, inpatient) from one another under certain circumstances.

Resource: CMS' MLN Matters article MM4215 clarifies that a physician may provide a consultation for another physician of the same specialty (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf).

The service must meet two minimum conditions, however:

1. Documentation must verify all elements of a consultation service, including a request for consult in both the requesting and consulting physicians' records, a reason for the consult request, and a written report from the consultant to the requesting physician outlining the consultant's findings and recommendations.

2. The consulting physician's knowledge and expertise must go above and beyond that of the requesting physician. In other words, the physician in the group being asked for the consultation must clearly have a skill set that the requester does not have. The chart must reflect the reason and justification (medical necessity) for the consult.

So if, for example, your physicians specialize in a particular anatomic area, condition or diagnosis, or interventional pain management procedure, they may meet the requirement that they have knowledge and expertise above and beyond that of the requesting physician, even if of the same specialty.

-- Answers to You Be the Coder and Reader Questions were provided by Scott Groudine, MD, an Albany, N.Y., anesthesiologist; Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver; and Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions of Leesburg, Fla.