Neurology & Pain Management Coding Alert

Quick: What three requirements distinguish a consult (99241-99263) from other inpatient and outpatient E/M services? If you can't answer, you need to brush up on the "Three R's" of consults: request, reason and response.

Be Sure to Have a Written Request
 
  "As specialists, many of a neurologist's E/M services will be consults," says Anita L. Carter, LPN, CPC, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J. "Essentially, a consult takes place when one physician seeks the opinion or advice of a second physician, usually a specialist, for the treatment or diagnosis of a patient."

 Carter warns that the physician must meet three very specific criteria before you may claim a consult: "I won't even consider reporting a consult code unless the physician has documented the request, reason and report that distinguish a consult from a 'standard' office or hospital visit."

 This request is the first of the three elements that distinguish a consult from other E/M services. As explained by the Medicare Carriers Manual (MCM), section 15506, a consult must be "requested by another physician or other appropriate source" (except in the case of a patient- or insurer-generated confirmatory consult. See "Confirmatory Consults Follow Different 'Request' Criteria"  for more information).

 "The request should be in writing and documented in the patient's medical record," Carter says. "If a request isn't there, as far as the insurer is concerned a consult didn't take place." In an emergency department or an inpatient 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, according to the MCM.

 Any physician may request a consult from any other physician and may even provide a consult for his or her own patient as long as you follow all other guidelines (as outlined below). An "other appropriate source" generally means 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." But a school nurse, for instance, may not qualify, depending on the individual insurer's guidelines. If you have any doubts about what your payer considers an "other appropriate source," ask for its guidelines in writing.

 In addition to a request, there must be a documented reason for the consult. "As with any service, the payer wants you to show medical necessity," says Kimberly Jawidzik, CPC, a coder with MedAssure LLC in Minneapolis. "The requesting physician should specify exactly why he or she is asking for a consult why it is required." For example, if a diabetic patient has loss of sensation in his feet, the requesting physician should note this (as well as other relevant signs, symptoms and conditions) and ask that the neurologist evaluate the patient for nerve damage or other possible problems.

 The final requirement to bill a consult is a written response. "The whole point of the consult is to provide an opinion," Jawidzik explains. "Following the visit, the consulting physician must prepare a written report of his or her findings for the referring physician." MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician" [emphasis added] and kept as part of the medical record (a "verbal" report is not good enough). Once again, if the physician does not provide a response, a consult has not occurred, and you cannot appropriately bill for one.

 Having met the requirements for request, reason and response, you must next choose among the categories of consultation: office or other outpatient (99241-99245), initial inpatient (99251-99255), and follow-up inpatient (99261-99263).

 Office or other outpatient consult codes describe "consultations provided in the physician's office or in an outpatient or other ambulatory facility," CPT states. For example, a patient presents to his primary-care physician (PCP) with symptoms of carpal tunnel syndrome (CTS), 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. 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 required. After testing, the neurologist confirms a diagnosis of CTS and prepares a report to the requesting physician, outlining his findings.

 In this case, you would report the appropriate outpatient consultation code (9924x) along with the code(s) for the NCS (9590x, depending on the type[s] of study performed), Sandham says. Bill any subsequent visits by the same patient for treatment of the CTS with the appropriate office outpatient codes (9921x).

 You may report a consultation given in the emergency department (ED) by a non-hospital-based physician if the ED physician or other physician attending the patient requests it.

 You should use the initial inpatient consultation codes to report consultations provided for hospital inpatients and those in partial hospital settings or nursing facilities, CPT states. The same physician may report only one inpatient consult per inpatient stay. For additional consults during the same inpatient stay, report the follow-up inpatient codes (discussed below). If the patient is discharged and readmitted later, however, you may report another initial inpatient consult by the same physician (if it is properly requested and documented), Sandham says.

 Report follow-up inpatient consultation codes for completion of an initial consult or when the attending physician requests a subsequent consult during the same inpatient stay, CPT says. For example, the neurologist receives a request to examine in the hospital a patient complaining of numbness in the legs, and makes a diagnosis of neuropathy (355.8). In this case, you should code the appropriate initial inpatient consultation code (9925x) along with any diagnostic tests performed (for example, a nerve conduction study, 9590x).

 The neurologist does not assume responsibility for treating the patient, but several days later receives a second consult request for the same patient during the same stay (either for the same or for a different problem). To report this visit, use the follow-up consult code (9926x) best supported by the neurologist's documentation. (If the neurologist had assumed responsibility for treatment of the patient's neuropathy after the initial consult, you would report his or her follow-up visits using the appropriate subsequent hospital care code[s], 99231-99233.)

 If the same patient is then discharged and readmitted at a later date, and the neurologist is once again called on to see him for the neuropathy or a different problem, you may again report an initial inpatient consult code, Sandham says.

 You may bill a consult in addition to "any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of the initial consultation," CPT says. "Even if a consulting physician runs some tests or makes recommendations for treatment, it's still a consult if all the requirements are documented," Jawidzik says.

 Some payers may not reimburse consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans. In July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless of whether treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs.

 The 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" (note: "referral," in this instance, is simply another term for transfer of care). "If the physician doesn't accept complete responsibility for the patient's condition, you can still report a consult, regardless of other services provided," Sandham says.

 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)," the MCM states.

 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."

 In the above example involving the patient diagnosed with CTS, the neurologist may bill a consult even though he 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), according to CPT guidelines.

 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, Carter says. 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.