Neurology & Pain Management Coding Alert

Question: My physician is being referred patients for -consults- by hospital physicians. When I bill, I am not sure if I should code for a new patient office visit or office consultation. How can I tell the difference?

Oregon Subscriber

Answer: To be able to report a consultation code (99241-99255), your physician's visit with the patient must first meet a few requirements. Traditionally, to code a consultation (99241-99255), the encounter had to meet three requirements:

- Request for opinion

- Rendering of services

- Report to the requesting source.

A year ago, CMS added reason to the consultation R-s. Transmittal 788 requires that the requesting physician document the request and the reason for a consult in the patient's medical record.

Important: These are Medicare guidelines only, but private payers generally accept them as well.

Key point: When the physician visits with a patient and renders an opinion for a requesting physician about a patient's condition and then the patient returns to the requesting physician for treatment, it is usually a consultation.

If your doctor is not asked for his opinion about the patient's problem, and he does not provide his opinion on the patient's status during the encounter, it is not a consult.

Alternative: If your physician doesn't meet the consult requirements, and the patient has not seen a physician in your practice within the past three years, you should instead select an appropriate-level new patient E/M visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...).

Possible fifth R: Billing and coding experts suggest that you pay attention to a fifth R of consultations: return. This helps to demonstrate that the patient only came to see you about a specific problem and that your neurologist is returning the patient to the requesting physician for the treatment of that problem. You need to show that there is no transfer of care.

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 Mary H. McDermott, MBA, CPC, director of billing quality assurance, Clinical Practice Association, of Johns Hopkins University in Baltimore.