Neurosurgery Coding Alert

You know that you need to specify the three R's to justify a consult code. But you must also be careful to avoid "transfer of care" language or risk losing reimbursement by billing a lower-paying visit, coding experts say.
 
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," says Kimberly Jawidzik, CPC, a coder with MedAssure LLC in Minneapolis.
 
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 physicians meet all consultation criteria and no transfer of care occurs. "If the physician doesn't accept complete responsibility for the patient's condition, you can still report a consult, regardless of other services provided," says Anita L. Carter, LPN, CPC, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J.
 
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.
 
In the above example involving the patient with a suspected brain aneurysm (see "Consults" article on page 76), the surgeon 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. If the surgeon subsequently assumes responsibility for treatment of the patient, report the visits using the appropriate established outpatient codes (99211-99215) or procedure codes.
 
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.