Neurosurgery Coding Alert

Experts advise you on choosing a consult category

After you've documented a request, reason and response, how should you go about choosing a correct consultation category? The answer is in the documentation, coding experts say. Follow these examples when selecting the appropriate code from one of three consult categories:

Office or other outpatient (99241-99245): These codes describe consultations the physician provides in the office or in an outpatient or other ambulatory facility, CPT states.
 
For example, a patient presents to his primary-care physician (PCP) with extreme lower-back pain radiating to the right leg, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. The PCP documents these symptoms and requests a consult from the neurosurgeon.
 
Following examination and testing in her office, the neurosurgeon confirms that the patient has disk degeneration in the lumbar area and prepares a report to the requesting physician, outlining her findings.
 
In this case, you would report the appropriate outpatient consultation code (9924x), Callaway says. Bill any subsequent same-patient visits for treatment of the same condition with the appropriate office outpatient codes (9921x).

Initial inpatient (99251-99255): Use these codes to report consultations the neurosurgeon provides for hospital inpatients and those in partial hospital settings or nursing facilities, CPT states.
 
Remember that the same physician may report only one inpatient consult per inpatient stay, says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern New Jersey. For additional consults the neurosurgeon provides during the same inpatient stay, report the follow-up inpatient codes (discussed below). If the attending physician discharges the patient and readmits him or her later, however, you may report another initial inpatient consult by the same physician (if another physician has properly requested and documented the consult), Callaway says.
 
For example, an orthopedic surgeon requests a consult from the neurosurgeon for a patient recovering from spinal surgery and complaining of back pain (724.2). The neurosurgeon reports this consult using the appropriate-level initial inpatient code (99251-99255). Three weeks later, the same patient re-enters the hospital for a different problem. During this visit, the same neurosurgeon again receives a consult request from the patient's attending physician (either for back pain or for a different problem). Because this is a separate inpatient stay, the surgeon should once again claim an initial inpatient consult (for instance, 99253, Initial inpatient consultation for a new or established patient...), as long as he documents the service.

Follow-up inpatient (99261-99263): Report follow-up inpatient consultation codes when the initial consult requires a subsequent visit to complete the evaluation, or when the attending physician requests a subsequent consult during the same inpatient stay, CPT says.
 
For example, the neurosurgeon receives a request to examine in the hospital an incapacitated patient with spinal stenosis (724.00) who has not responded to rest and physical therapy. In this case, you should code the appropriate initial inpatient consultation code (9925x), along with any diagnostic test the surgeon performs, Hofbeck says.
 
The surgeon 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 surgeon's documentation. (If the surgeon had assumed responsibility for treatment of the patient's condition after the initial consult, you would report his or her follow-up visits using the appropriate subsequent hospital care codes, 99231-99233).
 
If the same patient is then discharged and readmitted at a later date, and the surgeon once again treats the patient for stenosis or a different problem, you may report an initial inpatient consult code, Callaway says.