Neurology & Pain Management Coding Alert

Consultations and referrals for care are the lifeblood of many neurology practices. For example, a primary care physician (PCP) has a patient with severe, recurring headaches. Is it a neurological problem? Does the patient suffer from migraines? The PCP sends the patient to a neurologist in your practice, asking the specialist to examine the patient and either rule out a neurologic etiology or offer an opinion as to the cause of the problem. The neurologist performs a workup, orders several diagnostic tests, and rules out the presence of any neurological cause. He then writes a report indicating this to the PCP.

In another common situation, a person, due to illness or injury, develops a lesion on the brain causing an aphasiaan impairment in his ability to use or comprehend speech. The persons PCP knows that this neurological injury is beyond his scope of practice and refers this patient to a neurologist, asking him or her to diagnose the specific cause of the aphasia and treat the patient for the problem.

How should these visits be reported? Are they consultations (99241-99245, office or other outpatient consultation, new or established patient)? Or are they referrals (a transfer of the patients care), which the neurology practice would code with the office/outpatient evaluation and management (E/M) codes (99201-99205, new patient; 99211-99215, established patient) instead of the consult codes?

The answer for the above examples is both. The first example is a consultation. The neurologist receives a request for an opinion, evaluates the patient, and makes a recommendation back to the original physician. He does not follow the patients care.

The second example is a transfer of care of the patient for that injury. The neurologist assumes care of the patient for the aphasia and the lesion that caused it, while the PCP handles the other healthcare needs of that patient.

Telling the Difference is Tricky: Consult or Transfer of Care

Coders are frequently confused about the correct way to report consults and referrals. Many health organizations and third-party payers use conflicting and confusing terminology. For example, many managed care plans call any specialist the patient sees other than the PCP a referral, whether the specialist assumes the care of the patient or not. Members of the managed care plan are instructed to get the physician to fill out a referral form anytime they want to see a specialist. And doctors frequently consider any treatment of a patient at the request of another physician to be a consultation.

But, says Terry Fletcher, CPC, CCS-P, a healthcare coding consultant and coding educator with McVey Associates in Novato, CA, the CPT manual has specific rules to determine which visits should be reported as consultations and which ones should be considered transfers of care.

The most basic rule to remember is that a consultation is for your opinion and advice only, she explains, quoting the CPT definition.

According to CPT, a consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or appropriate source. ...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 .... In the office setting, the appropriate established patient code should be used.

In fact, many coding educators advise specialists to view consultations as having three essential components:

1. the request for an opinion;

2. the examination of the patient and review of medical
information pertaining to the case; and

3. the report back to the original physician. If any one of these elements is missing, it is difficult to justify reporting the service as a consultation.

If a physician sends a patient to a specialist with an indication that the specialist is expected to assume care of the patient for that medical condition, then the visit is not a consultation, but constitutes a transfer of care, states Arlene Morrow, CPC, CMM, principal of AM Associates, a healthcare consulting firm in Tampa, FL.

If the patient is coming in and the treatment is pretty much known [ahead of time], then it is going to be pretty difficult to say that it is a consultation, she advises.
Primary care doctors commonly send patients to the neurologist with instructions to consult and treat, a confusing term which actually indicates that the specialist is to assume the treatment of the patienta transfer of care under Medicare and most third-party payer rules.

Els Brooks, practice manager of Community Neurology Clinic in Duluth, GA, says it is unusual for her practice to even report a consultation code. Ive been here 11 months and I think I have seen only three, she says.

In most cases, the neurologist assumes the care of the patient, and the visit is reported with a high-level E/M code, either 99204 or 99205, she says.

We have referrals for a lot of different thingsepilepsy, seizures, post-concussion syndrome, multiple sclerosis, dementia, cerebral palsy, and a lot of motor vehicle accident injuries, she notes. Most of the time, we end up taking over care for these patients.

The only situation in which they have a true consultation, Brooks feels, is when the patient is sent by a physician requesting an opinion and the neurologist doesnt find a neurological reason for the medical problem. Sometimes we will have patients with unexplained headaches or back pain, and the neurologist will see them to rule out any other cause, she says.

In both situations, Brooks says her office writes a letter of report back to the referring physician. But, she only reports a consultation code when the neurologist gives his opinion on the patients care without assuming treatment. However, according to experts, this is not entirely correct coding and Brooks could be losing revenue.

Starting Treatment Not Necessarily an Assumption of Care

Sometimes, the neurologist may order extensive diagnostic tests in order to render his opinion. Or, in some specialties, the physician may diagnose a minor problem that can be treated quickly. Both actions have been held by some third-party payers to indicate initiation of treatment and, therefore, a transfer of care.

That is not necessarily the case. CPT specifically states, a physician consultant may initiate diagnostic and/or therapeutic services.

The Medicare manual says you can initiate therapeutic services on the same day as a consult, but that doesnt necessarily mean you can do it, adds Fletcher, indicating that some third-party payers and some carriers consider it a transfer of care and will downcode the visit to a regular E/M code or bundle the services into one code.

The Health Care Financing Administration (HCFA) is considering a revision of its rules that would clearly permit consultation and treatment on the same day, says Morrow.

Morrow is also quick to note that many requesting physicians have contracts with payers that stipulate conditions under which certain tests and diagnostic procedures are covered.

Some doctors want you to call them before you take an x-ray, she says. Other doctors want you to just do the workup and not bother them. It can vary.

Morrow recommends neurologists devise a simple consult request form that is pre-printed with check-off boxes to give the consultant instructions. Questions should cover things like: whether the consulting doctor should call the requesting doctor with his evaluation, what medical records have been sent over with the patient, what tests have already been performed and any procedures for authorizing new tests.

Documentation of Consults is Essential

Medicare and many managed care plans have stepped up their audits of consultation claims, because they suspect many groups are billing the higher-paying code for visits that should be reported with the standard office visit codes.

For every consult you report it is essential that you document the three components of a consultation (see list in first column on page 2) and keep evidence in the patients medical record, say both Morrow and Fletcher.

First, you must have documentation of the request for an opinion. In some cases, this may come in the form of a phone call from the requesting physician to the neurologist. If so, the neurologistat the very leastshould document the time the call was received and that it was to request a clinical opinion. This documentation should be kept in the patients medical record.

Second, the neurologist should clearly document the exam and any diagnostic tests or procedures performed to reach an opinion. If the requesting physician has stipulated he or she should be notified before any tests are ordered, this communication should also be included in the record.

Third, and this can be the most important piece, a written letter of report should be sent back to the requesting physician detailing the neurologists opinion. The language used in the report should specifically indicate that the neurologist is rendering an opinion to the PCP. The report should not contain statements that could be interpreted to mean the neurologist has assumed care for the patient.

Many specialists, who actually provided only a consultation, have sent letters back to the PCP beginning with statements like: Thank you for referring Mrs. Smith to me.

Even if the neurologist is only rendering an opinion in the letter, this statement could cost him the consultation charge by using the word referral.

In addition to this advice, Morrow recommends that neurology coders familiarize themselves with the specific portions of the Medicare manual (Section 15506) that cover consultation requirements.