Neurology & Pain Management Coding Alert

Question: One of my multiple sclerosis (340) patients was admitted to the hospital by her cardiologist. The cardiologist requested that I follow the patient pre- and postoperatively to help manage her severe spasms. The chart states that I am consulting, but I dont know if I can bill a consult, because I know the patient and have seen her in my office many times. My office manager told me that each doctor following the patient in the hospital has to have a different diagnosis unique to the problem theyre addressing with the patient to ensure reimbursement. Is this accurate?

Maryland Subscriber

Answer: Your situation would not meet the criteria of a consult (99251-99255) because the neurologist was asked to manage a particular aspect of care (the spasticity), and not to render an opinion, as would be required of a true consult, says Brenda Messick, CPC, senior consultant at Gates, Moore & Co., a physician practice management firm in Atlanta. The neurologist should bill the subsequent hospital care codes (99231-99233).

Also, the neurologist is no longer required to treat a different diagnosis than the other physicians treating the patient. If a patient with one diagnosis requires two physicians of different specialties, then each physician can bill for his or her individual services so long as the services are medically necessary.

The Medicare carrier in Maryland is Trailblazer. Its review policy refers to this as concurrent care and requires that the role of each physician be defined clearly to determine correct coverage. Trailblazers policy states, Coverage can be allowed if each physicians services are established as reasonable and necessary as the result of an active concurrent role in the patients treatment. This requirement can also be fulfilled if the patients 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.

The policy adds, 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 this case, the patients heart problems and multiple sclerosis most likely would qualify as multiple medical conditions.