Neurology & Pain Management Coding Alert

Find out if you're set to properly code your neurologist's consultation services this year by checking your answers to the three quiz questions against this answer key.

When your neurologist sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221-99223). If the documentation for the E/M service does not meet the requirements of the lowest level initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor's (MAC) or carrier's policy.

Problem: The lowest initial hospital care code (99221) requires a minimum of a detailed history and detailed exam. When your neurologist's documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). "Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in  Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the "unlisted" CPT code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

For example, WPS Medicare states on its Web site: "Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM)."

"Check with your carrier," Buechner advises. "Code 99499 is the correct coding choice by CPT rules." Somepayers, such as Highmark, don't seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code "that most appropriately describes the level of services provided," notes MLN Matters article MM6740.

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you're coding for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code. This will denote the admitting physician who is overseeing the patient's care, "as distinct from other physicians who may be furnishing specialty care," according to CMS Transmittal 1875 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

Example: Your neurologist is the admitting physician for a patient with new onset of right-sided paralysis (344.9, Paralysis, unspecified) and aphasia (784.3). The neurologist examines the patient andformulates an assessment and treatment plan. You should append modifier AI to 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive  history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the problem[s] requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit).

Remember: The new modifier is made up of two letters. "Some people are interpreting the new modifier as a one," Cobuzzi says. "But it's two letters, A and I," she reminds coders. Think: "A-eye."

Don't even think about billing a consult to Medicare -- even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultation codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare.

The MSP "will not pay for consults," says Samantha Daily, a medical biller for a practice in Portland, Ore. Official word: MLN Matters article MM6740 indicates the following: "In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation ...]. If the primary payer for the service continues to recognize consultation codes" you should bill for secondary payment from Medicare in one of the following two ways:

• Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or
• Bill the primary payer using a consult code, and then report the amount paid by the primary payer, along with an acceptable E/M code (that is equal to the consultation code/service paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the neurologist may not know whether a hospitalized patient is covered by Medicare or another insurance when he documents his consultation and determines code assignment. You will need to be able to glean an appropriate E/M code from your neurologist's consult documentation if the patient ends up also having Medicare as secondary insurance.