Neurology & Pain Management Coding Alert

You can report a new initial consult for each inpatient stay

If you're having a hard time deciding between the codes for follow-up inpatient consults and subsequent hospital care services, consider whether your neurologist assumes primary responsibility for a portion of the patient's care or if he simply provides an opinion to another physician.
 
1. Place of Service Matters

If you're reporting an inpatient consultation, the patient your neurologist sees must have been admitted as an inpatient. Although this sounds obvious, mistakes occur all the time.

"Not all facility settings qualify as 'inpatient,' " says Marvel J Hammer RN, CPC, CHCO, president of MJH Consulting in Denver. "You can easily make a mistake by thinking, 'The doctor saw the patient in the hospital, so it must be an inpatient service.' But the ED [emergency department], for instance, is an outpatient setting, and doctors provide consultations in the ED all the time."

Specifically, inpatients include patients admitted to hospitals, partial hospital settings or nursing home residents.

Watch for: You should not use inpatient codes for patients the neurologist consults with in the ED, as well as domiciliary, rest (boarding) homes, custodial care or other "nonskilled" facilities.

2. Claim 1 Initial Consult per Patient Admission

If you've determined that the patient qualifies for inpatient status - and the available documentation supports a consultation (see "Consults 101," later in this issue) - you should choose an appropriate-level initial inpatient consultation code (99251-99255) for the neurologist's first meeting with the patient.

Remember: "You can report 99251-99255 only once per patient per hospital stay," says Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook.

Example: The managing physician requests that your neurologist provide a consultation for a hospital inpatient complaining of generalized numbness (782.0, Loss of skin sensation), especially in the lower limbs.
 
The neurologist meets with the patient and, after taking a history and exam, conducts electromyographic (EMG) testing (for instance, 95864, Needle electromyography; four extremities with or without related paraspinal areas). The neurologist prepares a report of his findings and shares them with the managing (requesting) physician.

In this case, you should report the initial inpatient consult (for instance, 99254, Initial inpatient consultation for a new or established patient ...) along with the EMG (95864). You should also be sure to append modifier 26 (Professional component) to 95864 because the neurologist provided the test in a facility setting.

Keep in mind: If the patient is later re-admitted to the hospital, you may report another initial consult.

Example: The patient in the above example leaves the hospital but is re-admitted three days later. The managing physician again requests a consult from your neurologist. You may again report 99251-99255, as appropriate.

3. Additional Consults + Same Stay = Follow-up

There are two instances when you should assign a follow-up inpatient consult (99261-99263), Hammer says:

1. When the physician sees the patient in the hospital a second time because he was unable to complete his assessment at the first visit.

2. When an attending physician initially requests a consult from the specialist for an inpatient, but because of the length of the stay and changes in a patient's medical status, the attending requests a second "follow-up consult" to see if the consulting physician has any more recommendations given the changes in patient status.

Example: Two weeks after the initial consultation but during the same inpatient stay, the managing physician in the above example requests a second consultation because the patient has developed new symptoms.

In this case, choose a follow-up inpatient consult, 99261-99263, as supported by the neurologist's notes.

Documentation tip: Codes 99261-99263 don't require your neurologist to send a written report to the attending physician. The neurologist can record the request, review and report in the patient's shared medical chart.

Get ready for a change: Evidence suggests that CPT will eliminate the follow-up inpatient consult codes (99261-99263) for 2006. If the rumors are true, beginning next January you will report all subsequent hospital care using 99231-99233.

4. Don't Confuse Follow-up With Subsequent Care

If your neurologist assumes responsibility for a portion of the patient's care following an initial inpatient consult, you should report the subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) - rather than the follow-up inpatient consult codes - for the neurologist's follow-up visits with the patient, Ferragamo says.
 
Example: After the initial inpatient consultation for the patient in the first example above, the neurologist arrives at a diagnosis of neuropathy (355.8). He reports his findings back to the requesting/managing physician, who asks the neurologist to assume responsibility for that portion of the patient's care. You should report all of the neurologist's subsequent visits with the patient during the same inpatient stay using 99231-99233.