Neurosurgery Coding Alert

Choose one initial consult per inpatient stay

Just because your surgeon meets with a patient in the hospital at the request of another physician doesn't mean that you can report an inpatient consultation (CPT 99251 - 99263 ).

The solution? Check your place of service carefully. Here are full details on the four most important factors to keep in mind when considering inpatient consult codes.
 
1. Watch the Place of Service

If you-re going to report an inpatient consultation, the patient your surgeon sees must have been admitted as an inpatient. Although this sounds obvious, mistakes occur all the time.

-Not all facility settings qualify as -inpatient,- - says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. -You can easily make a mistake by thinking, -The doctor saw the patient in the hospital, so it must be an inpatient service.- But the ED [emergency department], for instance, is an outpatient setting, and doctors provide consultations in the ED all the time.-

Specifically, inpatients include patients admitted to hospitals or partial hospital settings, as well as nursing home residents.

Watch for: You should not use inpatient codes for patients the surgeon consults with in the ED, for patients designated -observation status,- or for residents of domiciliary, rest (boarding) homes, custodial care or other -nonskilled- facilities.

2. Claim an Initial Consult First

If you-ve determined that the patient qualifies for inpatient status--and the available documentation supports a consultation (see -Billing a Consult?- at right)-- you should choose an appropriate-level initial inpatient consultation code (99251-99255) for the surgeon's first meeting with the patient.

Remember: -You can report 99251-99255 only once per patient per hospital stay,- says Michael A. Ferragamo, MD, FACS, clinical assistant professor at State University of New York, Stony Brook.
 
Example 1: The managing physician requests that the neurosurgeon provide a consultation for a bedridden hospital inpatient. The surgeon meets with the patient, conducts a full history and examination and diagnoses incapacitating sciatica caused by a displaced intervertebral disk (722.10 ). The neurosurgeon then prepares a report of his findings and shares them with the managing (requesting) physician.

In this case, you should report an initial inpatient consult (for instance, 99254, Initial inpatient consultation for a new or established patient ...).

Keep in mind: If the patient is discharged and later re-admitted to the hospital, you may report another initial consult, as long as you meet all the consult criteria.
 
Example 2: The patient in the above example leaves the hospital only to be re-admitted three days later. The managing physician once again requests a consult from the neurosurgeon because the patient shows new symptoms of neck pain. You may again report 99251-99255, as appropriate.

3. Same-Stay Consult Means Follow-up Code

For the remainder of 2005, there are two instances when you should assign follow-up inpatient consult codes 99261-99263, Hammer says:

1. When the physician sees the patient in the hospital a second time because he was unable to complete his assessment or establish a definite plan of care at the first visit, or;

2. When an attending physician initially requests a consult from the specialist for an inpatient, but because of the length of the stay and changes in a patient's medical status, the attending requests a second -follow-up consult- to see if the consulting physician has any more recommendations given the changes in patient status.

Example 3: The neurosurgeon provides an initial consult (99251-99255) to evaluate an inpatient suffering injury from an auto accident. He examines the patient and shares the information with the managing physician.

The next day during the same inpatient stay, the patient complains of headaches (784.0), nausea (787.02), dizziness (780.4) and other symptoms. Fearing intra-cranial bleeding or other delayed injury, the managing physician requests a second consult from the neurosurgeon. The neurosurgeon examines the patient a second time to evaluate the new symptoms and provides a report to the requesting physician.

In this case, you choose a follow-up inpatient consult (99261-99263) as supported by the surgeon's notes.

Documentation tip: Unlike an outpatient consultation (99241-99245, Office consultation for a new or established patient ...), 99261-99263 don't require the consulting surgeon to send a written report to the attending physician. The surgeon can document the request, review and report in the patient's shared medical chart.

Expect changes: CPT will eliminate 99261-99263 in 2006 (see -CPT Streamlines Consult Coding for 2006,- below, for complete information).

4. If Surgeon Assumes Care, Choose 99231-99233

If your surgeon assumes responsibility for any portion of the patient's care following an initial inpatient consult, you should report the subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) for the surgeon's follow-up visits, Ferragamo says.

Example 4: The neurosurgeon shares his diagnosis of displaced intervertebral disk to the requesting physician in the first example above. The requesting physician asks the neurosurgeon to assume responsibility for that portion of the patient's care. Therefore, you should report all of the surgeon's subsequent visits with the patient during the same inpatient stay using 99231-99233.