Neurology & Pain Management Coding Alert

Providers often pay little attention to confirmatory consultation codes (99271-99275), but with the U.S. Office of Inspector General (OIG) once again targeting E/M services and consults in particular for increased scrutiny in 2003, physicians and coders must use extra caution to report such services accurately. By carefully documenting the confirmatory nature of the consultation and appending modifiers as appropriate, you can greatly increase your claims' accuracy and the odds of receiving reimbursement for payer-mandated services.

A confirmatory consultation is a lot like any other inpatient or outpatient consultation (99241-99263), with a few important differences. "The primary difference between a confirmatory consult and a 'run-of-the-mill' consult is that during a confirmatory consult the physician is offering a second or third opinion, either to concur or to disagree with the advice, opinion or diagnosis provided by another physician, often of the same specialty," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "In contrast, during a 'normal' consult a physician refers the patient to a different physician, usually with more specialized knowledge. In this case, the consulting physician is offering a 'first' rather than a 'second' opinion."

Another distinguishing feature of a confirmatory consult is that a patient, a member of the patient's family or an insurer can request the service, whereas only a physician or "other appropriate source" (that is, a medical professional) can request an inpatient or outpatient consult as described by 99241-99263. In other words, if a patient (or family member, insurer, etc.) wants a second opinion before proceeding with treatment or a major diagnostic procedure or accepting a diagnosis, the patient can request a confirmatory consult without the intervention of a physician. In fact, for billing purposes, confirmatory consult codes are reserved for a second opinion generated by a nonphysician or nonbilling provider only, says Carol Pohlig, BSN, RN, CPC, reimbursement analyst and senior coding and education specialist in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

In all cases, the consulting physician must be aware of the confirmatory nature of the opinion sought. As noted in CPT, you may provide a confirmatory consult in any setting (inpatient or outpatient) and should expect to provide an opinion or advice only.

Like other consultations (and all E/M services), you must choose the appropriate level of confirmatory consult according to the key components of history, examination and medical decision-making although time may become the primary factor if more than 50 percent of the visit is spent in counseling and coordination of care. If you do assign a code based on time, you must document the total time spent with the patient or family member, along with the proportion of time spent in counseling/coordination of care, and give an overview of the topics discussed.

Insurers often view confirmatory consults as medically unnecessary and/or a duplication of services, and therefore will not reimburse for them. "Basically, if the payer doesn't mandate the service, it's unlikely to be covered," Jandroep warns. Therefore, unless you are certain that the payer has requested the consult, you should complete an advance beneficiary notice (ABN) to inform the patient that he or she may be responsible for any uncovered charges.

Note: A few payers may pay for second opinions, but do not count on this. Always get an ABN if the service is not mandated. Medicare Part B will not mandate (or reimburse for) a confirmatory consult.

If the payer does request the consult (for instance, prior to authorizing expensive treatment or testing), be sure to append modifier -32 (Mandated services) to the appropriate confirmatory consult code. In this case, the insurer should reimburse you in full for the service, as well as any covered diagnostic services required to evaluate the patient properly (note that in some cases the results of tests performed by the first physician may be available to the second physician). If the recommendations of the first or second physician differ regarding the need for a particular treatment or testing, the payer may request and reimburse for a third opinion.

As an example, an elderly patient complains of back pain and requests trigger-point injections. The patient's primary-care physician refers the patient to a neurologist, who determines that although the patient's pain arises from mild neurological problems, there is no medical justification for trigger-point injections and recommends other, more conservative treatment methods. The patient's daughter, seeking a second opinion, requests that a different neurologist examine her father. In this case, the second neurologist is providing a confirmatory consult, but because an insurer did not mandate the service, the physician notifies the patient that he will likely be responsible for payment and asks the patient to sign an ABN.

In a second example, a neurologist recommends immediate surgical intervention to treat serious, bilateral carpal tunnel syndrome (354.0). Unwilling to proceed with such expensive treatment without first exploring other options, the insurer requests a confirmatory consult from a second neurologist. In this case, the second neurologist will bill the consult, as well as any necessary diagnostic exams, with modifier -32 appended.