Neurology & Pain Management Coding Alert

Properly determining and reporting consultations remains a persistent coding challenge to neurology coders. Like other E/M services, consult codes are chosen according to the three elements of history, examination and medical decision-making. But to bill consults, neurologists must also meet other important criteria. Consults are frequently performed in neurology offices, and the accuracy of coding significantly affects the bottom line. And, if not properly documented, these services may be easily confused with referrals or transfers of care.
Meet Medicare Requirements for Billing
 
 
CPT Includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263) and confirmatory (99271-99275). Section 15506 of the Medicare Carriers Manual (MCM) says that to bill a consultation, you must meet three guidelines (the Three R's):
 
1. Request: A consult is provided by a physician whose opinion or advice regarding the E/M of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).
 
Any physician may request a consult from any other physician and may perform a consult for his or her own patient as long as all criteria are followed. "Other appropriate source" is generally understood to mean any individual who can act on the advice/information provided by the consulting physician. According to the MCM, "Limited licensed practitioners, e.g., nurse practitioners or physician assistants, may request a consultation." A school nurse, however, may not qualify, depending on the individual carrier's guidelines. Check with the insurer if there is any doubt that an appropriate source has requested a consult.
 
2. Reason: A request for a consultation from an appropriate source and the need for consult (medical necessity) must be documented in the patient's medical record.
 
According to the MCM, "In an emergency department or an in- or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request ... may consist of an appropriate entry in the common medical record." In an office setting, there must be a specific written request for the consultation from the requesting physician, or the consultant's records "must show a specific reference to the request."
 
3. Response: After the consultation, the consultant must prepare a written report of his or her findings that is provided to the referring physician.
 
MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician."
 
Any consult may be billed in addition to "any specifically identifiable procedure (i.e., identified with a specific code) performed on or subsequent to the date [...]