Neurology & Pain Management Coding Alert

Connecticut Subscriber

Answer: Consultations as an E/M category require meeting all three key components, not just the medical decision making level. The level of service must be coded on the "lowest" key component -- that is, if the provider performed and documented a detailed history, but performed and documented a comprehensive exam and moderate decision making, the provider still can't report a level-four consult code.

Likewise, if you have a comprehensive history but only detailed or expanded problem focused exam, again there is no level-four consult.

Exception: The only exception to this would be if the provider spends more than 50 percent of the visit in counseling and coordination of care (C/C) with the patient, then C/C is the determining factor, not the three key components.

The documentation requirements for a level-three consultation are a detailed history, detailed exam, and low-complexity decision making. The documentation requirements for a level-four consultation are a comprehensive history, comprehensive exam, and moderate decision making. Although a higher level of decision making is one factor in the level of service, it is certainly not the only factor.

Although your neurologist is correct to document additional problems that have an impact on his level of medical decision making, even though he is not treating those problems, this is not enough by itself to support coding 99244.

Don't forget: You need to be sure you meet all requirements before you code a consult, including documentation of a consult request, of the neurologist rendering the service, and of the neurologist reporting findings and recommendations to the requesting physician.