Neurology & Pain Management Coding Alert

You-ll treat -second opinions- like any other E/M service

The AMA will streamline E/M coding by deleting follow-up inpatient (99261-99263) and confirmatory (99271-99275) consultations for CPT 2006.

What will the changes mean to your neurology practice? For starters, you-ll report all inpatient follow-up visits as subsequent hospital care.

Don't Sweat Consult Criteria for Hospital Follow-ups

Beginning Jan. 1, 2006, you should report all facility visits, except the first, during the same inpatient stay using subsequent care codes 99231-99233 (hospital) or 99311-99313 (nursing facility).

Under current guidelines, the neurologist may report a follow-up inpatient consultation for subsequent visits during a single inpatient stay, as long as the visit meets the criteria of request with reason, opinion rendered, and report, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. The elimination of 99261-99263 for 2006 means that beginning in January, you-ll no longer have that option--even if the service meets the requirements of a consult and the neurologist does not assume responsibility for any portion of the patient's care.

Initial Inpatient Consults Are Still Valid

You should still report an initial inpatient consult (99251-99255) for the neurologist's first visit with the patient per inpatient stay, as long as the service meets all the requirements of a consult, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Example: The managing physician requests that your neurologist provide a consultation for a hospital inpatient complaining of generalized numbness and loss of skin sensation (782.0, Loss of skin sensation), especially in the lower limbs. The neurologist documents the request, examines the patient and shares his findings with the managing physician.

In this case, report an initial inpatient consult code (for example, 99254, Initial inpatient consultation for a new or established patient ...), as well as any diagnostic tests the neurologist provides (for example, 95864, Needle
electromyography; four extremities with or without related paraspinal areas).

Don't forget: You-ll need to append modifier 26 (Professional component) to any diagnostic tests that the neurologist provides in the hospital setting.
 
The next day (let's call it Jan. 3, 2006), the managing physician again asks the neurologist to examine the patient because of new symptoms. Once again, the neurologist documents the managing physician's request, examines the patient and shares his findings. For the follow-up visit, you should claim subsequent hospital care (for instance, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Although this visit looks like a consult, you must report subsequent care because codes 99261-99263 will not be valid for 2006.

Don't Worry ... Be Happy

Some good news: Deletion of 99261-99263 will ease documentation requirements for physicians and headaches for coders trying to choose between follow-up consults and subsequent hospital care, Hvizdash says. You can simply choose 99231-99233 for hospital inpatients or 99311-99313 for nursing facility patients.

-I-m happy to see [the follow-up consult codes] go,- Hvizdash says. -They-re confusing for a lot of physicians, especially new ones.-

And some great news: As a bonus, -Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,- Callaway says.

Say Goodbye to 99271-99275

CPT 2006 will eliminate 99271-99275 (Confirmatory consultation for a new or established patient ...). Therefore, you-ll have to report either a standard outpatient E/M service (99201-99215) or consultation (99241-99245)--depending on the circumstances--for so-called -second (or third) opinions.-

-With no codes for confirmatory consults in 2006, you-d treat these services like any other E/M service,- Hvizdash says. -If the neurologist receives a request from another physician to examine the patient, renders an opinion and provides a response, you have an outpatient consult. If the visit does not meet those requirements [such as when a patient -self-refers-], you-d charge for a standard office visit.-

Example: A patient diagnosed with severe bilateral carpal tunnel syndrome, or CTS (354.0), seeks a second opinion before undergoing surgery. Your neurologist meets with the patient and provides a full workup. The examination is extensive, and the neurologist conducts electromyography (EMG) and nerve conduction studies (NCS) to confirm the CTS diagnosis.

In this case, you should report an appropriate-level new patient visit (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...). You should also report the EMG and NCS diagnostic testing (for instance, 95861, Needle electromyography; two extremities with or without related paraspinal areas; and 95903, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study).

Seek an ABN

You should obtain an advance beneficiary notice (ABN) from a patient prior to rendering the service if you know that the patient is seeking a second opinion or confirmation of a diagnosis or treatment plan. The ABN lets the patient know that he may be responsible for payment if the insurer deems the service unnecessary.

Here's why: Many payers (including Medicare) have not covered confirmatory consultations because the insurers considered such second opinions a -duplication of services,- and therefore medically unnecessary.

This problem may continue to haunt physicians who provide second opinions for patients. Because another physician has already examined the patient and provided an opinion, the payer may deem any attempt to re-examine the patient a duplication of services--even if you bill the care as an office visit or inpatient or outpatient consultation.