Neurology & Pain Management Coding Alert

Question: An ER doctor requested our neurologist's opinion on a Medicare patient. Our provider completed the consultation while the patient was in the ER. The patient was later transferred to observation status by the hospitalist. Our neurologist did a follow-up visit on the next day while the patient remained in observation. On the third day, due to the patient's deteriorating condition, the attending physician ordered the patient to be admitted to the hospital, and the patient's hospital status was changed to inpatient. After the hospital admission, our neurologist saw the patient in follow-up on two more days. Medicare had problems with our listing the place of service as 23 for our neurologist's E/M services. How should I code this encounter?
Vermont Subscriber

Answer: Since CPT no longer has follow-up consult codes, after the first consultation E/M service you should consider your neurologist's E/M services as either established patient visits (99212 " 99215) or subsequent hospital visits:

- 99231 -- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity
- 99232 -- ... an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity
- 99233 -- ... a detailed interval history; a detailed examination; medical decision making of high complexity.

Place of service (POS) codes change depending upon the location where the E/M service was provided.  It's correct to report place of service code 23 (Emergency room " hospital) for your neurologist's consultation service. However, the place of service code would be 22 (Outpatient hospital) for the E/M service while the patient is in observation. The POS would then change once more to 21 (Inpatient hospital) for your provider's subsequent E/M visits after the patient was admitted as an inpatient.

Break it down: For your neurologist's first consult, you should code 9924x at POS 23. When the patient was placed in observation status, you should code 9921x at POS 22 for the follow-up. After the patient became an inpatient and your neurologist made two additional follow-up visits, you should code 9923x at POS 21.