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 consultants and tend not to take over a patients care, except for certain, specific conditions that are usually chronic (such as Parkinsons disease or seizure disorders). Therefore, they most often charge for consultations, not new patient office visits, our sources say.

Under the new guidelines, the only time its a new patient instead of a consult is if the referring doctor states ahead of time in writing that the neurologist is taking on the complete care and treatment of the patient and the neurologist documents acceptance prior to seeing the patient, says Douglas M. Loop, CPA, administrator of Loma Linda University Neurology Associates, a 14-provider practice in Loma Linda, CA.

If a patient is referred for headaches and theres a neurological deficit, the neurologist may order an MRI and see the patient back to go over the results, he says. In some instances, with headache patients, the neurologist may make the initial prescription to get the patients treatment started. But other than one or two follow-up visits, that usually ends the neurologists involvement in the case. We expect the primary care physician to take over from there, says Loop. We do not take over the complete care of the patient so the first visit is definitely a consultation.

Inter-group Referrals

The transmittal also makes it clear that the receiving physician can bill for a consultation if the request came from a physician in the same practice. This is the most meaningful part of the revision, according to Loop. Neurology has a lot of subspecialties, he says. We have subspecialists in movement disorder, epilepsy and multiple sclerosis, he says. For example, a patient is referred to our practice for a gait imbalance. If the patient sees a general neurologist and it turns out the patient has Parkinsons, the general neurologist may refer the patient to our Parkinsons subspecialist. That encounter now can be a consultation. Before, we were just charging an established patient office visit.

The transmittal is very clear on this point. Carriers are directed to pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met. And because the group practice physicians share a patients medical record, the consultants report may consist of an appropriate entry in the common medical record. Some experts recommend, however, that the requesting physician in an inter-group situation review and initial the consultants findings in the chart. Such documentation clearly shows an auditor that the requesting physician received and reviewed the report.

Referral Letters No Longer Necessary

Three elements must be present to bill a consultation code: a request for the consultation by the requesting physician, a review of the patients case, and a report issued back to the requesting physician, reviews Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., of Spring Lake, NJ. The biggest change in the August transmittal is that all the neurologist needs to do to substantiate that a request was made for a consultation is to document it in the medical record, says Brink, who has consulted with neurology practices. The neurologist can write, The patient is here today for a consultation at the request of so-and-so, says Brink. Before, there had to be a written request. As noted above, the neurologist was always capable of initiating diagnostic tests during the consult, says Brink. For me, the biggest change is that HCFA has relaxed the rules for a written request from the requesting physician.

Transfer of Care

Occasionally, a referral is made and a consultation is not appropriate, explains Brink. If an orthopedist is referring a patient to a neurologist to get an opinion of the patients problem, thats a consultation. But if the orthopedist did surgery for a herniated disc yet the patient still suffers pain, the orthopedist has done all that he can. He decides to send the patient to a neurologist for pain management. If the orthopedist tells the neurologist, I have done all I can do, I would like you to take over care, that is a new patient office visit for the neurologist, not a consult. Thats because a transfer of care has occurred.

Brink further explains that there are a variety of situations that would call for consultations. If the orthopedist asks the neurologist, Is this patient a candidate for pain management? and the neurologist reports back, Yes, this patient is a good candidate, and I would be happy to take over his pain management care at your request, that is a consultation. Likewise, if the neurologist says, I feel that this patient is probably a good candidate for pain management, but I want to do an EMG first. Ill notify you of the results and then will take over the care of the patient at your request, that is also a consultation.

Neurologists must remember, says Brink, is that they just cant assume the care. Unless the requesting physician specifically requests that the neurologist take over the care, there is no transfer of care.

Refer vs. Request: What the neurologist writes in the chart is very important regarding documenting requests for consultations. Brink recommends that if the care of the pat-ient is transferred to you, you should say, Doctor Ortho-pedist referred this patient to me. On the other hand, if the patient is sent to you for a consult, you should say, This patient is here today at the request of Dr. Orthopedist. In other words, use the word refer for when care is being transferred, and use the word request for a consult.

Backbilling

Should you do any backbilling, if you have already miscoded consultations as office visits since August? No, backbilling is not recommended in this instance and could cause more problems than its worth. First, nothing in the transmittal addresses a retroactive effective dateor any date at all. Usually, if backbilling is allowed, it is mentioned in the transmittal. Second, backbilling could red-flag you for an audit. In addition, remember that the letter from the consulting neurologist to the requesting physician is extremely important. It is the backbone of the consultation. Are you sure you sent letters like that if you were only billing an office visit? Many physicians didnt do the letter; they said, Why bother? because they werent billing a consultation anyway. If, when the carrier publishes this new policy in their bulletin there is a retroactive date indicated for billing, then you could check your records to make sure of the written reports and file for the consultations rendered on or after that date.

What Is a Consultation? A consultation, according to the Health Care Financing Administration (HCFA), includes a history, examination, and a written report filed with the patients record maintained by the attending physician. That report, if the medical record is shared as in a general neurologist/subspecialist neurologist inter-practice referral, can be in the form of notes in the patients chart. Furthermore, a consultation must involve a medical judgment that ordinarily requires a physician, HCFA states. And as always, the consultation claim must contain a diagnosis.

What Is Not a Consultation? Here are three general examples that do not satisfy HCFAs criteria for consultations: 1. Standing orders in the medical record for consultations. 2. No order for a consultation. 3. No written report of a consultation.