Neurology & Pain Management Coding Alert

 
Consultation codes are chosen using the same criteria as other E/M codes. With the exception of the follow-up codes 99261-99263 -- which apply only to previously seen patients -- consult codes (99241-99255 and 99271-99275) may be used for both new and established patients. All of the three key areas of history, examination and medical decision-making (MDM) must meet or exceed the requirements of the level chosen.
 
History may be either problem focused, expanded problem focused, detailed or comprehensive, as follows:
 
Focused -- chief complaint, brief history of present illness (HPI)
 
Expanded focused -- as above, but including problem-pertinent system review (i.e., review of at least one item in the "system review" portion of the CPT introduction to the Evaluation and Management (E/M) Services Guidelines)
 
Detailed -- as above, with extended HPI, problem- pertinent system review extended to limited number of additional systems and a pertinent past, family and/or social history (PFSH) directly related to the presenting problem
 
Comprehensive -- as above, with review of systems directly related to problems in HPI, plus all additional systems and a complete PFSH.

 
The examination may also be either problem focused, expanded problem focused, detailed or comprehensive:
 
Focused -- limited exam of affected body area or organ system
 
Expanded focused -- as above, plus other symptomatic or related organ system(s)
 
Detailed -- as above, with extended examination of affected body area(s)
 
Comprehensive -- general multisystem exam or complete exam of a single organ system.

 
MDM is defined as either straightforward, low complexity, moderate complexity or high complexity:
 
Straightforward -- a minimal number of possible diagnoses and/or management options, minimal or no amount/complexity of data and minimal risk of complications, morbidity and/or mortality
 
Low complexity -- a limited number of possible diagnoses and/or management options, a limited amount/complexity of data and low risk of complications, morbidity and/or mortality
 
Moderate complexity -- multiple possible diagnoses and/or management options, a moderate amount/complexity of data and moderate risk of complications, morbidity and/or mortality
 
High complexity -- an extensive number of possible diagnoses and/or management options, an extensive amount/complexity of data and high risk of complications, morbidity and/or mortality.

 
To qualify for a given level of MDM, two of the three requirements for that level must be met or exceeded. According to CPT, "Co-morbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision-making."
 
Note: See charts on the back of this page for the requirements of each level and type of consultation.
  
Coding Examples

 
For instance, says Laureen Jandreop, OTR, CPC, CCS-P, CPC-H, consultant-owner and trainer for A+ Medical Management and Education in Egg Harbor City, N.J., at the request of the primary care physician (PCP), a patient presents to the neurologist's office for a consultation. The patient shows signs of Parkinson's disease. This illness may mimic other problems during its initial phases. Therefore, a comprehensive history and examination are warranted. In this case, also, there are many probable diagnoses and a high probability of severe, prolonged functional impairment -- which qualifies as high-complexity MDM. For this visit, report 99245. 
 
In a second example, provided by CPT, the neurologist is called to provide a follow-up consultation for re-evaluation of a stroke patient in the hospital (the neurologist had performed an initial consultation days earlier, without plans to return or to participate in the patient's ongoing management). The neurologist also develops a plan for initial rehabilitation services. The consult includes a problem-focused history, an expanded problem-focused exam and a moderate level of MDM (moderate number of treatment options and moderate chance for complications). Because the follow-up inpatient consult codes require that only two of the three components be met for a particular level, this service would qualify as a 99262.
 
According to CPT, if all other requirements are met, consultations may be billed using time as the primary factor if counseling and/or coordination of care constitutes more than 50 percent of the face-to-face encounter (i.e., time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) between the physician and the patient or "parties who have assumed responsibility for the care of the patient."
 
For instance, a patient suffers a transient ischemic attack (TIA, or "mini-stroke"). The neurologist provides a consult at the PCP's request. Based on the elements of history, exam and MDM, this 65-minute visit qualifies as a 99242. In this case, however, 40 minutes were spent counseling the patient on ways to prevent future problems and coordinating care. Because more than half the visit was spent on these activities, time may be used to assign the proper level. Therefore, 99244 is warranted.