Neurology & Pain Management Coding Alert

Question: Since CPT doesn't carry confirmatory consultation codes, how should I report the service when a patient asks for a second opinion from our neurologist?
Illinois Subscriber

Answer: If a patient or family comes to your practice and requests a second opinion, report the appropriate E/M office visit code (99201-99215).

For example: A new patient seeks a second opinion from a neurologist regarding treatment for a previously diagnosed polyneuropathy condition. Notes indicate that during the encounter, your neurologist obtained an expanded problem focused history, performed a detailed exam, and completed a low-complexity medical decision making. On the claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making) for the E/M service.

Also: When the neurologist performs a second or confirmatory opinion in the outpatient setting at the request of a physician or other appropriate source, you would consider the office consultation codes (99241-99245) depending on documentation.