Neurology & Pain Management Coding Alert

A primary-care physician refers a patient to a neurologist, who determines that nerve block injections are necessary. The neurologist performs one series of blocks and sends the patient back to the primary care physician for general care. How should the neurologist code the first visit: new patient office visit, or consultation? The answer used to be: It depends on how your carrier interprets the Medicare definition of a consultation. The answer now is: Its a consultation. In August, the Health Care Financing Administration (HCFA) issued its now-famous Transmittal 1644, a revision to Section 15506 of the Medicare Carriers Manual.

The revision means four things:

1. that a neurologist can charge a consultation and also go on to treat the patient, providing that the patients entire care has not been transferred to the neurologist by the referring physician;

2. that a neurologist can refer a patient to another neurologist of a different subspecialty in the same group and the second neurologist can charge a consultation;

3. all that is necessary to document the request for a consultation is a note in the patients chart; and

4. in the inter-group referral case, the consultants findings do not need to be in a letter to the referring physician but can be documented in the shared medical record.

Consult and Treat

According to the transmittal, a consultation:

1. must be provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician;

2. must have a documented need; and

3. must be followed up with a written report for the requesting physician.

The transmittal also discusses consultation followed by treatment. It directs carriers to pay for a consultation regardless of treatment initiation unless a transfer of care occurs, providing that the above three criteria are met. A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of the referral, and the receiving physician documents approval of care in advance. The receiving physician would report a new or established patient visit depending on the situation. Therefore, the consultation cannot be billed when only a transfer of care occurs.

The consultation clarification is great news for neurologists, who get many referrals and dont usually have the care transferred. Consultation codes (99241-99245 for outpatient consultations) pay more than office visit codes (99201-99205, 99211-99215).

Most compliance experts believe that neurologists could have been billing consultations all along. But before Transmittal 1644, the definition of consultation was more vague, allowing individual carriers to have more or less rigid definitions. Now, all carriers must adhere to Transmittal 1644.

Neurologists generally act as [...]