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 of the initial consultation," according to CPT.

Using Outpatient Consultation Codes

 
Office or other outpatient consultation codes are assigned "to report consultations provided in the physician's office or in an outpatient or other ambulatory facility," CPT states. A non-hospital-based physician may report a consultation given in the emergency department (ED) if the ED doctor or other physician attending the patient requests it. More than one consult may be reported by the same doctor for the same patient (for the same or a new problem) as long as the above three requirements are met on each occasion. Any subsequent office visits initiated by the consulted physician, however, must be reported as an office visit (99211-99215).
 
For example, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a patient presents to his or her primary care physician (PCP) with symptoms of carpal tunnel syndrome (CTS). The PCP documents these symptoms and requests a consult from the neurologist. The neurologist examines the patient and determines that further diagnostic testing, specifically nerve conduction studies (NCS), is necessary. After testing, a diagnosis of CTS is confirmed and the neurologist prepares a report to the requesting physician, outlining his or her findings. The neurologist also recommends techniques to the patient to alleviate symptoms. In this case, the appropriate outpatient consultation code (9924x) should be reported, along with the code(s) for the NCS (9590x, depending on the type[s] of study performed). Any subsequent visits by the same patient for treatment of the CTS would be billed with the appropriate office outpatient codes (9921x).
  
Using Inpatient Consultation Codes 

 
Initial inpatient consultation codes are used to report consultations provided for hospital inpatients and those in partial hospital settings or nursing facilities. The same physician may report only one inpatient consult per inpatient stay. Additional consults during the same inpatient stay should be billed using the follow-up inpatient codes. If the patient is discharged and readmitted later, however, another initial inpatient consult by the same physician may be reported if it is properly requested and documented.
 
Report follow-up inpatient consultation codes to complete the initial consultant or when the attending physician requests a subsequent consult during the same inpatient stay. They are used for established patients only. CPT further specifies that if the consulting physician initiates treatment at the initial consult and then participates in the patient's management, the subsequent hospital care codes, rather than the follow-up consult codes, should be used.
 
For example, the neurologist receives a request to examine in the hospital a patient complaining of numbness in the legs, and arrives at a diagnosis of neuropathy (355.8). In this case, the appropriate initial inpatient consultation code (9925x), along with any diagnostic tests performed (e.g., NCS 9590x), should be reported. If testing is done using the hospital's equipment, modifier -26 (professional component) should be appended to the test code(s).
 
In this case, the neurologist does not assume responsibility for treating the patient but receives a second consult request for the same patient during the same stay (either for the same or a different problem). To report this second consult, use the follow-up consult code (9926x) best supported by the neurologist's documentation. Alternatively, if the neurologist had assumed responsibility for treatment of the patient's neuropathy after the initial consult, he or she should code follow-up visits using the appropriate subsequent hospital care code(s), 99231-99233.
 
The same patient is then discharged and readmitted at a later date, and the neurologist is once again called upon to see him or her for the neuropathy or a different problem. The initial inpatient consult codes should be reported, Sandham says.

"Request" Rules Differ for Confirmatory Consults

 
According to CPT, "A 'consultation' initiated by a patient and/or family, and not requested by a physician," is reported using the confirmatory consultation codes. In addition, these consults may be billed when an insurer or other physician seeks a second or third opinion. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code (99271-99275) with modifier -32 (mandated services) appended. These consults may be provided in any setting.
 
For instance, before allowing treatment for the patient in the above example, the insurer seeks a second opinion from a different neurologist. This second neurologist evaluates the patient in the hospital at the insurer's request and performs the necessary diagnostic tests. The session would be coded 9927x for the consult (depending on documentation) with modifier -32 appended, along with test codes with modifier -26 appended.

Be Aware of Transfer of Care and "Referrals"

 
In the past, some payers have not reimbursed consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans, says Sally Crone, CPC, office manager of Ephrata Neurology in Ephrata, Pa. In July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs. MCM section 15506 further explains, "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance" [emphasis added]. "Referral," in this instance, is simply another term for transfer of care.
 
If a transfer of care does occur, "The receiving physician would report a new or established patient visit, depending on the situation ... and setting (e.g., office or inpatient)," according to the MCM.
 
Note: A new patient is defined as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."
 
For instance, in the above example of the patient diagnosed with CTS, the neurologist may bill a consult even though he or she also performed diagnostic testing and recommended steps to alleviate symptoms. These procedures/services do not constitute a transfer of care. Subsequently, however, the neurologist may assume responsibility for treatment of the patient, including physical therapy. These subsequent visits should be reported using the appropriate established outpatient codes, 99211-99215.
 
Although "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms when requesting or describing a consultation, Crone advises. Auditors and payers may automatically consider "referral" or "treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming complete care of the patient, and therefore may not reimburse for a legitimate consultation.
 
Note: See insert in this issue for the requirements of each category and level of consultations.