Neurosurgery Coding Alert

You-ll probably call on office E/M codes for -second opinions-

The AMA has decided to delete follow-up inpatient consult codes (99261-99263) and confirmatory consultation codes (99271-99275) for CPT 2006. The most significant change for neurosurgery practices will be that you-ll report all inpatient follow-up visits as subsequent care.

Forget Consult Criteria for Hospital Follow-ups

Beginning Jan. 1, 2006, you should report all facility visits, except the first, during the same inpatient stay using subsequent care codes 99231-99233 (hospital) or 99311-99313 (nursing facility).

Under current guidelines, the surgeon may report a follow-up inpatient consultation for subsequent visits during a single inpatient stay, as long as the visit meets the criteria of request and reason, opinion rendered and report, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the surgery department at UPMC Presbyterian-Shadyside in Pittsburgh. The elimination of 99261-99263 for 2006 means that beginning in January, you-ll no longer have that option--even if the service meets the requirements of a consult and the surgeon does not assume responsibility for any portion of the patient's care.

Initial consult codes are still valid: Be aware, however, that you will still be able to report an initial inpatient consult (99251-99255) for the surgeon's first visit with the patient per inpatient stay, as long as the service meets all the requirements of a consult, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Example: The neurosurgeon sees an inpatient suffering injury from an auto accident at the request of the patient's managing physician. The surgeon documents the request, examines the patient and shares his findings with the managing physician.

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

The next day, the managing physician again asks the surgeon to examine the patient because of new symptoms. Once again, the neurosurgeon documents the request, examines the patient and shares his findings.

For the follow-up visit beginning in January, you should claim subsequent hospital care (for instance, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Although this visit looks like a consult, you must report subsequent care because 99261-99263 will not be valid for 2006.

Change Is Good

The good news: Deletion of 99261-99263 will ease documentation requirements for physicians and headaches for coders trying to choose between follow-up consults  and subsequent hospital care, Hvizdash says. You can simply choose 99231-99233 for hospital inpatients or 99311-99313 for nursing facility patients.

-I-m happy to see [the follow-up consult codes] go,- Hvizdash says. -They-ve been such a confusing topic for a lot of physicians, especially new ones.-

Even better news: As a bonus, subsequent hospital care codes generally reimburse better than have follow-up inpatient consultations. -Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,- Callaway says.

Confirm E/M Services for -Second Opinions-

CPT 2006 will also eliminate services 99271-99275 (Confirmatory consultation for a new or established patient ...). Therefore, you-ll have to report either a standard outpatient E/M service (99201-99215) or consult (99241-99245)--depending on the circumstances--for so-called -second (or third) opinions.-

-With no codes for confirmatory consults in 2006, you-d treat these services like any other E/M service,- Hvizdash says. -If the surgeon receives a request from another physician to examine the patient, renders an opinion and provides a response, you have an outpatient consult. If the visit does not meet those requirements [such as when a patient -self-refers-], you-d charge for a standard office visit.-

Example: A patient with a diagnosed arteriovenous malformation, or AVM (447.0, Arteriovenous fistula, acquired), seeks a second opinion before undergoing surgery. He schedules an appointment to see your surgeon.

The surgeon meets with the patient and provides a full workup. The examination is extensive, and the surgeon orders magnetic resonance angiography of the cranium.

In this case, you should report an appropriate-level new patient visit (such as 99205, Office or other outpatient visit for the evaluation and management of a new patient ...). You may also report the MRA interpretation (for example, 70546-26, Magnetic resonance angiography, head; without contrast material[s], followed by contrast material[s] and further sequences; Professional component), as long as the neurosurgeon prepares a separate report and a radiologist or other physician doesn't claim this service first.

Seek an ABN

You are wise to obtain an advance beneficiary notice (ABN) from a patient prior to rendering the service if you know that the patient is seeking a second opinion or confirmation of a diagnosis or treatment plan. The ABN lets the patient know that he may be responsible for payment if the insurer deems the service unnecessary.

Here's why: Many payers (including Medicare) do not cover confirmatory consultations because they consider such second opinions (especially when generated by the patient or patient's family) a -duplication of services,- and therefore medically unnecessary.

This problem may continue to haunt physicians who provide second opinions for patients. Because another physician has already examined the patient and provided an opinion, the payer may deem any attempt to re-examine the patient a duplication of services--even if you bill the care as an office visit or inpatient or outpatient consult.