Neurology & Pain Management Coding Alert

Question: When my neurologist refers to another physician within our group, should I code for an established patient, new patient, or a consult? Our neurologists may refer to one another based on a provider's subspecialty, such as MS, epilepsy, etc.

Nebraska Subscriber

Answer: Medicare's Claims Processing Manual states, "Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional's knowledge."

Consultations within a group are allowed if they meet the criteria for a consultation as indicated above. The appropriate code range would be 99241-99245 (Office consultation for a new or established patient ...) for office site of service. If the E/M service does not meet the criteria for a consultation -- that is, your neurologist asks the partner to take over care -- then you would report the visit with the established patient visit codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...)