Neurology & Pain Management Coding Alert

You may find this scenario familiar: You're in an office with three, four, or even six or more neurologists. Dr. Smith examines an established patient with a new complaint of gradual weakness over a period of the last few weeks, which Dr. Smith suspects may be toxic myopathy (359.4). Dr. Smith refers the patient to Dr. Jones in the same office, because Dr. Jones specializes in this disorder. How do you choose the best E/M code?

The crux of the issue is, what service is Dr. Smith requesting of the second neurologist (Dr. Jones) with the patient's condition "subspecialty"? The key to coding this E/M service is the intention of Dr. Smith -- transfer of care, with Dr. Jones taking over care of the condition? Or is Dr. Smith only asking Dr. Jones to render his opinion?

Dr. Smith asks his partner Dr. Jones to see this patient. The patient has a condition that Dr. Jones specializes in and Dr. Smith wants Dr. Jones to take over care of the patient's condition. This is a transfer of care, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education LLC in Ohio. "The only option would be to use the established patient outpatient E/M codes, 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...)," she says.

If Dr. Smith and Dr. Jones have different subspecialties within the same group -- if one is a general neurologist and another specializes in muscular dystrophies and other myotonic disorders, for example --would this then allow the patient to be considered a new patient according to the decision tree in the CPT manual? According to the January 1998 CPT Assistant, "If the subspecialty is part of the same group, then the patient is not considered a new patient." The June 1999 issue, however, states, "it is possible for a patient receiving professional services from a subspecialist within the same group to be considered a new patient to another physician in the group. For example, if the subspecialists within the group practice have a separate tax identification number for their subspecialty, different from that of the general group tax identification number, then the patient receiving professional services from the subspecialist may be considered a new patient."

Many payers use the taxonomy table classification to determine different subspecialties. For neurology, the following are some of the possibly different subspecialties:

• neurology

• clinical neurophysiology

• diagnostic neuroimaging

• neurodevelopmental disabilities

• neurology with special qualifications in child neurology

• neuromuscular medicine

• vascular neurology.

Remember: CPT Assistant further instructs you to familiarize yourself with your insurance companies' various reimbursement and reporting policies on new and established patient definitions when different specialties and subspecialties in the same group provide the encounters.

The other scenario is if Dr. Smith asks his partner Dr.Jones to see this patient to only provide his opinion on the patient's condition and/or advice on a plan of care. If Dr. Jones is not being asked to take over care but rather render his opinion and send the patient back to Dr. Smith for management, then the services could be considered to be an outpatient consultation E/M service reported with 99241-99245 (Office consultation for a new or established patient, which requires these 3 key components ...).

The Medicare Claims Processing Manual, Chapter 12 states, "A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients' complete care for the condition and does not expect to continue treating or caring for the patient for that condition. Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional's knowledge."

If Dr. Jones' services don't meet the consultation criteria and the patient is seen in the office, report the appropriate level of "Office or Other Outpatient Services" E/M code. If Dr. Jones does meet the consultation criteria, report a consultation code (99241-92245).

FYI: "Dr. Jones may initiate diagnostic testing or treatment for the condition for which Dr. Smith saw the patient," says Barbara J. Cobuzzi, MBA, CPC,CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions. "Dr. Smith should be involved in the decision making if he wants Dr. Jones to pursue the plan of care," she adds. Dr. Smith does not have to be the one to implement the plan of care, as he may not have the skill set to implement the care plan.