Neurology & Pain Management Coding Alert

Although Medicare and CPT have clarified their positions on consultation reimbursement, some neurologists still have problems getting paid for them because the physician seeking the surgeons opinion referred the patient. By properly showing that the physician seeking the surgeons opinion requests only that, and no transfer of care has occurred, neurologists can ensure they are properly paid for the consultative services.

In August 1999, the Health Care Financing Administration (HCFA) issued transmittal number 1644, clarifying the distinction between a new patient visit (99201-99205) and a consultation (99241-99255). This clarification proved necessary because many Medicare and third-party payers had been issuing denials or reductions for consultations when the consulting physician initiated any form of treatment, even if complete care for a presenting problem was not transferred to the consultant.

To throw further light on the subject, the CPT 2000 introductory text to the consultation codes was revised: A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician
consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patients medical record. The consultants opinion and any services that were ordered or performed also must be documented in the patients medical record and communicated by written report to the requesting physician or other appropriate source.

But even with the HCFA clarification and the revised CPT language, many neurologists continue to report difficulties in gaining proper reimbursement for consultations. Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic in Marshfield, Wis., a 650-physician group regional healthcare system with more than 50 specialties including neurology, says that the use of the word referral in documentation related to consultations is one of the major problems.

Referral is an ambiguous term that is responsible for much of the confusion surrounding consultations, Fischer explains. She says that in medicine, refer means send, and it is used widely by physicians. But it is not in the CPTs introductory text for consultations, and with good reason. A physician may refer for treatment, refer for care, or refer for an opinion. Despite indications by the American Medical Association (AMA) that auditors should not view the word referral as an indication of a complete transfer of care for a particular condition, a red flag often is raised when auditors see this word in a physicians records, and initial consultation codes (99241-99245) often are denied or changed to new patient visits, which reimburse at a considerably lower rate.

Classifying a Transfer of Care

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, views the August 1999 clarifications positively. Previously, if a primary care physician (PCP) sent a patient to a neurologist with even a hope that the neurologist would be able to treat him or her, carriers considered that a transfer of care already had occurred, Sandham says.

Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at University of Pittsburgh Medical Center at Shadyside in Pittsburgh, and president of the American Association of Electrodiagnostic Medicine (AAEM), indicates that the primary issue in determining if a neurologist should bill for a consultation or a new patient visit is whether he or she is being asked for an opinion or advice by the requesting PCP. Even if treatment ultimately needs to be rendered by the neurologist, there is a very good chance that the PCP will remain involved in the overall care of the particular problem. In such a case, a complete transfer of care for the problem has not occurred.

Physicians should note that HCFA has defined a complete transfer of care as relating to a physicians overall treatment of a patient, and not to the initial treatment by a specialist for a specific problem. After the initial consultation is complete, the partial transfer of care would allow continuing treatment by the specialist as concurrent care.

Further, HCFA allows use of follow-up consultation codes when subsequent visits are to complete the initial consultation. Although not specified in the regulations, when a diagnosis and plan of care have been established, and the requested advice or opinion has been provided, Medicare and third-party payers generally accept that the initial consultation is complete .

The Three Rs for Defining a Consultation

Sandham says that there are three requirements for any encounter to be coded as a consultation: request, reason and response.

1. Request: The consultation must be requested by another physician or other appropriate source. An other appropriate source generally is viewed as a professional who can act on the advice given. If the patient accesses the specialist directly, it is not a consultation. This request must be documented in the patients medical record. If the requesting physician sends a note or card, place this document in the patients file. Otherwise, the neurologist serving as consultant is responsible for documenting the request.

2. Reason: Medical necessity must be shown for the consultation services provided. This also must be documented.

3. Response: According to CPT 2000, the consultant must furnish a written report to the requesting physician. The report should indicate findings, any treatments performed, and if the consultant elects to follow the patient. A physician generally does not remain as a consulting physician except in the rare instances when there is a further specific request by the patients PCP. As per CPT 2000, If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patients condition(s), the follow-up consultation codes should not be used.

Diagnosis Coding Is Critical

If the neurologist follows the patient of his or her own initiative for a particular problem while the PCP remains to treat the patient for a different problem, both
doctors seeing the patient may be submitting codes for regular evaluation and management (E/M) services. Under these circumstances, each doctor should use the most
specific ICD-9 code possible to reflect the portion of the patients overall care that each is treating.

For an inpatient consultation (99251-99255), the requesting physician and the consultant may share a patient chart. If so, the neurologist does not have to dictate a separate report, however, the consulting neurologist should note within that chart that he or she is seeing this patient at the request of the other physician.

If the consultation is performed because a third-party payer made a request for a second opinion, then the confirmatory consultation codes (99271-99275) should be
used. In this event, modifier -32 (mandated services) also should be reported for coding accuracy (payment will not be affected).