Neurology & Pain Management Coding Alert

Question: Recently, a private (non-Medicare) insurer requested that our neurologist provide a confirmatory consultation for another physician's patient. We have attempted to bill these types of services in the past at the patient's request, but we've always been left with an unpaid claim. How should we handle this?


Nevada Subscriber

Answer: Insurers often view confirmatory consults as medically unnecessary and/or a duplication of services, and therefore will not reimburse for them. If the insurer specifically requests the confirmatory consult, however, you have a much better chance of receiving reimbursement than if the patient requests the consult.

If the payer requests a confirmatory consult (for instance, prior to authorizing expensive treatment or testing), be sure to append modifier -32 (Mandated services) to the appropriate confirmatory consult code (99271-99275). The insurer should reimburse you in full for the service, as well as any covered diagnostic services required to evaluate the patient properly (in some cases, the results of tests performed by the first physician may be available to the second physician).

If the recommendations of the first or second physician differ regarding the need for a particular treatment or testing, the payer may even request and reimburse for a third opinion.

When a patient, rather than the insurer, requests a "second opinion," you should complete an advance beneficiary notice (ABN) to inform the patient that he may be responsible for any uncovered charges. A few payers may pay for second opinions, but you shouldn't count on it: An ABN is your best defense against an unpaid claim.

You should note that Medicare Part B payers will never request or reimburse for a confirmatory consult.