Neurosurgery Coding Alert

Self-Referrals and 'Recommendations' Don't Count
 
If a patient visits your surgeon at the "recommendation" of another physician or on his own accord, you must select a standard outpatient E/M code (99201-99205 for new patients, or 99211-99215 for established patients) to report the service.
 
"The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group," says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if "the attending physician did not specifically ask for an opinion or advice from the specialist." This request from the attending physician must be recorded in writing and be available as a part of the patient's medical record.

Some Care Doesn't Mean 'Transfer of Care'

You may report a consult even if your surgeon schedules testing or initiates care for the patient - as long as the visit meets the requirements of request, review and report. CPT 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." You should not code a new patient visit just because you see that a consulting physician has initiated diagnostic testing or treatment services.
 
Further, in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the consulting physician initiates treatment, as long as all consultation criteria are met and no transfer of care occurs.
 
Example: A primary-care physician requests that the neurosurgeon provide a consultation for a patient complaining of low-back pain. The surgeon meets with the patient, performs an exam and spends some time with the patient discussing possible diagnoses and treatment options. The surgeon prepares a report of her findings and sends them to the requesting physician, then recommends that the patient return soon for an epidural injection.
 
In this case, even though the surgeon discussed diagnoses with the patient and recommended potential treatment options, you may still report a consult. No transfer of care has occurred at this point, and the surgeon has met the requirements of request, review and report.
 
Appeal downcoded claims: Many insurance companies that see a consult code alongside a treatment or procedure will automatically downcode the claim to a new patient visit. You should appeal these claims (and your lost reimbursement) as long as you have proof that there was no intent to transfer care prior to that visit, Hammer says.
 
If Physician Takes Over Care, Use Outpatient E/M

If, after an initial consultation, the consulting physician accepts responsibility for the patient's condition, you must report all subsequent visits using the appropriate-level outpatient E/M code.
 
"A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance," explains the Medicare Carriers Manual, section 15506.
 
Example: Returning to the above case: After the initial consultation, the surgeon accepts responsibility for diagnosing and treating the patient's low-back pain. On subsequent visits, the surgeon will report established patient office visits (99211-99215), as well as any testing or treatment codes (such as spinal injections), as supported by documentation.