Neurosurgery Coding Alert

Heres when you can claim a consult rather than an admit/subsequent care code.

Did you know if your neurosurgeon manages the patients head injury while another physician takes care of everything else, then you should hold off on reporting an admission service? Given insurers interest in these codes, you should avoid making mistakes -- or else.

Face these four questions, and youll stay out of auditors crosshairs.

1. What Does Hospital Admission Entail?

You may report a hospital admission (99221-99223) for a neurosurgeon (or any other specialist) as long as the neurosurgeon assumes full responsibility for the patients care, says Dianne Wilkinson, RHIT, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

Example: From the emergency department the neurosurgeon admits a patient with head injuries. The patient may require the care of several specialists, such as a general surgeon, orthopedist, neurologist, and others, to deal with his injuries. As the admitting physician, the neurosurgeon would be responsible for the overall and ongoing care of the patient.

Only one physician can charge an admission. If two or more physicians co-manage a patient, you can only claim an admission for one physician. You would never have multiple admitting physicians, Wilkinson says.

In some cases, this means the attending physicians will have to decide who assumes overall care of the patient and therefore receives credit for the admission. Most trauma centers have protocols that outline which specialist will admit patients with multiple injuries (for instance, a trauma surgeon).

Warning: Several insurers have warned that specialists such as neurosurgeons often incorrectly bill for initial hospital visits. In many cases, the insurers argue, a neurosurgeons first encounter with a patient in the hospital comes at the request of another physician and therefore more likely qualifies as a consult rather than an admission (see below).

Bottom line: If the surgeon manages only a single body system (such as dealing with a head or spinal injury), and a different physician oversees the remainder of the patients care, the neurosurgeon cannot lay claim to the admission service.

2. What Should I Do in Co-Management Situations?

If two physicians co-manage a patient in the hospital, they should both bill subsequent care (99231-99233). Subsequent visits are high on Medicares radar, Wilkinson says. They are often under-documented, contain very little history, and not enough exam for the level chosen.

To claim subsequent care, the neurosurgeon should document that he has reviewed the patients records, test results, and status since the last assessment. In other words, all the normal E/M requirements exist for subsequent care. For a low-level inpatient follow-up (99231) this could include simple history or a problem-focused exam, and lowcomplexity medical decision making.

Watch out: Payers sometimes deny simultaneous subsequent care claims on the grounds that the patient didnt need multiple visits, but with a specialist and a primary-care physician, or two specialists, you can usually show theres medical necessity, especially for complex injury or illness or trauma cases.

3. When Can I Report a Consult?

When the neurosurgeon sees the patient for the first time in the hospital, you may sometimes claim a consult (99251-99255) rather than an admission or subsequent care code. Keep in mind, however, that the rules for a consult are quite stringent.

Remember: To report a consultation code (99241- 99255), you should extend the 3 Rs into 5 Rs, says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. They are:

" Reason for consultation

" Request for opinion

" Render an opinion

" Report back of findings: Your physician must provide a written report back to the requesting physician that describes the consulting physicians findings, recommendations, etc.

" Return: Discharge patient back to requesting physician.

Example: An emergency department physician asks the neurosurgeon to examine a patient complaining of headaches and dizziness following a fall and blow to the head. The neurosurgeon examines the patient for internal head injuries, finds no evidence of internal bleeding or other serious injury, and reports his findings back to the ED physician. Because of other concerns, the ED physician holds the patient for observation.

In this case, the neurosurgeon can properly report an initial inpatient consultation (such as 99253, Initial inpatient consultation for a new or established patient ...), while the ED physician will bill for the observation care (for example, 99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge ...).

4. Does an Encounter Over 2 Days Mean 2 Codes?

Just because the calendar date changes, you shouldnt try to bill two separate codes for the same service.

Example: The neurosurgeon sees the patient in the ED at 11:45 p.m. and decides to admit the patient at 12:03 a.m. Although the episode spans two separate days, this is still a single encounter. No payer will allow you to bill separately an ED visit before midnight and an admission after midnight. Rather, you should combine all the E/M services and report them using a single code (in this case, the admission).