Neurosurgery Coding Alert

A letter of findings to the first physician doesnt always equal a consult.

Choosing a consultation when documentation supports a referral could trigger refund requests.

When a doctor or other health care professional with a National Provider Identification number sends your neurosurgeon a patient, you have to determine what that provider is asking for. "It all boils down to intent," says Rena Hall, CPC, billing/insurance specialist at Kansas City Neurosurgery Group LLC in Missouri. In other words, "does Dr. A want an opinion or suggestion for treatment options, or does he want Dr. B to treat the problem from that point on?"

Think Consult When Opinion Is Sought

If the requesting physician says to your neurosurgeon, "You have expertise in this area, and I need your opinion on how to proceed with this patient who has this chief complaint," and documents that reason in the patients chart, that meets the first requirement. In a consultation, the requesting physician "loans" the patient to the consultant for a specific problem and asks for an opinion.

Your neurosurgeon may order or perform diagnostic testing, start treating the patient during the consultation visit, or assume care of the patients problem in a subsequent visit (a "transfer of care"). Whether or not your neurosurgeon treats the patient, if the initial visit is to provide the request-ing physician with a specialists advice on how to treat his patient, you can consider that visit a consultation. 

Example: A patient presents to the primary care physician (PCP) with chronic low-back pain, spreading into her legs. The PCP documents the symptoms and requests an opinion from a neurosurgeon. The neurosur-geon examines the patient and determines that further diagnostic testing, such as myelography, is necessary.
The neurosurgeon prepares the report to the requesting physician, outlining his or her findings.

In this case, you would report the appropriate outpatient consultation code (9924x) along with any diagnostic tests (for instance, 722xx, depending on the myelography) that you perform.

Remember: To report a consultation code (99241-99255), Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, has extended the three Rs into five Rs based on what Medicare has been looking for. They are:

" Reason for consultation

" Request for opinion

" Rendering of opinion

" Report back of findings: Your physician must provide a written report back to the requesting physician that describes the consulting physicians findings, recommendations, etc.

" Return: Discharge patient back to requesting physician.

Equate Assumption of Care With Referral

A "referral," on the other hand, assumes that one physician is handing the patient off to your neurosurgeon to take over care (which would also qualify as a transfer of care), Hall says.

The first physician is not requesting your neurosur-geons opinion or advice, and there is no requirement that your neurosurgeon share his findings or plans for treating the patient with the referring physician. Thats true even if your neurosurgeon does share his findings in the name of good physician relations. In other words, just because your neurosurgeon sends the first physician a letter with findings, its not necessarily a consultation.

To report an E/M visit for a transferred patient, you use the appropriate level initial or subsequent inpatient/
new or established outpatient visit code depending on the place of service (99201-99215, 99221-99233). 

Example: Your neurosurgeon receives a request to examine a bedridden patient in the hospital, arriving at a diagnosis of incapacitating sciatica caused by a displaced intervertebal disk (722.10). The neurosurgeon takes over responsibility for the patient.

You should report the visit using the appropriate subsequent hospital care code(s) (99231-99233).