Neurology & Pain Management Coding Alert

Question: A multiple sclerosis (340) patient's cardiologist admitted her to the hospital and requested that I follow the patient pre- and postoperatively to help manage her severe spasms. The chart states that I am "consulting." How should I report this service? Must each physician following the patient in the hospital have a different diagnosis to establish medical necessity and prove that there is no duplication of services?

Neurology Discussion Group Participant

Answer: Although the chart may say you're "consulting," the service does not meet the criteria of a consult (99251-99255) because the cardiologist asked you to manage a particular aspect of care (the spasticity) rather than to render an opinion. Therefore, you should report the subsequent hospital care codes (99231-99233), as supported by documentation, to claim services rendered.

In those cases when two or more physicians of different specialties provide concurrent care for the same patient, separate diagnoses are not required as long as the services are medically necessary. Medicare payers require that the role of each physician be clearly defined to determine correct coverage, however. For example, Maryland Medicare Carrier Trailblazer dictates, "Coverage can be allowed if each physician's services are established as reasonable and necessary as the result of an active concurrent role in the patient's treatment. This requirement can also be fulfilled if the patient's condition warrants the services of more than one physician on an attending, rather than a consulting, basis and all are determined to be reasonable and necessary." Trailblazer's policy continues: "In making this determination, the specialty of each physician will be considered since the presence of multiple medical conditions may require diverse medical or surgical services."

In your case the patient's heart problems and multiple sclerosis would likely qualify as multiple medical conditions, and therefore a separate diagnosis is not required.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.