Neurosurgery Coding Alert

Caution: CMS says you must avoid NPP split-visit billing with consultations

If your neurosurgeon provides consultations for other physicians, you now have clearer guidelines on when you can and can't report the service, thanks to a new CMS transmittal. Use these expert tips to find out how to take advantage of the consultation clarifications and to prevent denials.

The Physician's Area of Expertise Makes a Difference

One of the most significant CMS clarifications in Transmittal 788 says that if your neurosurgeon works in a group practice, you-ll now be able to report and be compensated for consultations that he provides for other physicians in the group. The key point in this new rule is that the consulting physician's knowledge and expertise must go above and beyond that of the requesting physician-s.
 
This requirement will apply to neurosurgical groups in which the physicians have subspecialties, as well as to more diversified groups that a neurosurgeon may be part of. -Previously, it was clear that if you had in one group an internist and a neurosurgeon, the internist could refer a patient to the neurosurgeon. What's different about this is that it's saying that one neurosurgeon can refer to another neurosurgeon,- says Eric Sandhusen, HC, CPC, director of compliance for the Columbia University department of surgery in New York -But again, there has to be that medical necessity.-

Tip: Your protocol cannot be that if a patient comes in to see Dr. A, he then automatically sends the patient over to Dr. B after he finishes his examination. Make sure your office can prove that the neurosurgeons have separate sub-specialties and that there is medical necessity for the second physician to see the patient. If you can show different areas of expertise, you shouldn't have concerns about this new clarification causing a -big- issue such as an investigation of fraud, says Rena Hall, CPC, coder for the Kansas City Neurosurgery Group in Missouri.

Transfer of Care Eliminates Consultation Code Options

Make sure you don't report a consultation if there is a transfer of care between physicians in the same group, says Nancy Reading, RN, BS, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, Utah.

Example 1: In a group of neurosurgeons, one provider specializes in spine surgery and another specializes in skull-base surgery. The spine surgeon sees a new patient who presents with headaches. The neurosurgeon orders an MRI, which shows a tumor that the spine surgeon doesn't feel qualified to handle. He asks the skull-base surgeon in his practice to take over the care of the patient. Since the spine surgeon is sending the patient to the other physician to care for this new problem, it's probably not a consult, Reading says.

Example 2: A neurosurgeon sends a patient to a colleague who has specialized expertise in the management of a particular disease process. The requesting physician has exhausted all known treatment options and wants the consultant's opinion on further treatment options. -This would certainly stand up as a request for opinion,- Reading says. You can report a consultation code for this visit.

Forego Split Visits for Consultations

The good news is that CMS has specifically said that your nonphysician practitioners (NPP) can report and request consultations. The bad news is that CMS has also clarified that you cannot report a consultation that is a shared or split visit between the neurosurgeon and the NPP. This may be a significant change for many physicians, Sandhusen says.

Often in neurosurgery practices, a nurse practitioner does the patient workup and then the neurosurgeon does a key portion of the service -face-to-face- and bills for the whole visit, Sandhusen says. CMS has specifically said this is not permissible with consultations. Therefore, when your neurosurgeon is performing a consultation, your office's nurse practitioner or physician assistant can only perform the review of systems or past medical, family and social history.