Neurosurgery Coding Alert

Before reporting consult services 99241-99263, your documentation must show that the service meets three basic requirements:

1. A physician or other appropriate source must request the consultation, and the reason for the request must establish medical necessity for the consulting physician to visit the patient. The consulting physician must record the request in his documentation.*

2. The consulting physician must document his visit with the patient and render an opinion regarding the patient's condition.

3. The consulting physician must prepare a written report of his findings and provide them to the requesting/referring physician (the consulting physician can record this information in the shared patient record for inpatient consultations).*

Remember: A consulting physician may initiate treatment and/or provide diagnostic testing and still report a consult. If, however, the physician accepts primary responsibility for the patient prior to the visit, a transfer of care has occurred, and you should report a new or established patient visit, depending on the situation and setting.

 * These rules do not apply to confirmatory consults (99271-99275). For these services, the request can come from the patient, insurer or other source, and the consulting physician need only provide an opinion on the patient's condition.