Neurology & Pain Management Coding Alert

Not every type of consult must meet the same requirements. Specifically, physicians providing consults to render second or third opinions can observe different request criteria.

 Although CMS guidelines as outlined in section 15506 of the Medicare Carriers Manual (MCM) state that a physician or other appropriate source must request a consultation, physicians may provide confirmatory consults (99271-99275) at the behest of a patient, the patients family, or an insurer seeking a second or third opinion prior to authorizing treatment without another physicians written request. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, you should report the appropriate confirmatory consult code (99271-99275, as supported by documentation) with modifier -32 (Mandated services) appended.

 For example, neurologist A provides a diagnosis of severe bilateral carpal tunnel syndrome (CTS) and recommends immediate surgical treatment. The insurer, seeking a second opinion before authorizing costly surgery, requests a confirmatory consult with neurologist B. Neurologist B evaluates the patient, provides a written response (for the insurer) and reports the confirmatory consult level supported by documentation (e.g., 99274) with modifier -32 appended. He or she may also separately report any required diagnostic testing (electromyography, nerve conduction studies, etc.).

 But if the patient and/or family requests a confirmatory consult, insurers (including Medicare) will not cover the service. In this case, you should ask the patient to sign an advance beneficiary notice (ABN) to guarantee payment.