Neurosurgery Coding Alert

Billing for consultations that result in the decision to perform surgery can be challenging, especially when they take place in the emergency department (ED). Accordingly, it is imperative to choose the correct E/M code to describe the role of the neurosurgeon in this process. With the appropriate E/M code and the addition of the correct modifiers, you can increase reimbursement and decrease denials.

Choosing the Correct E/M Code

In a case that came from a Neurosurgery Coding Alert subscriber, a doctor was called in to see a patient in the ED who was in an automobile accident and suffered damage to her spine. The neurosurgeon decided that the patient needed to have surgery immediately. The patient was admitted to the hospital with the neurosurgeon listed as the admitting physician. A coding dilemma arose: Should a consultation (99241-99245) or admission (99221-99223) code be billed?

The decision is not easy because of several factors, including whether the requirements for a consultation have been met, whether the referral came from a primary care physician or an ED doctor, and state-to-state and carrier-to-carrier variations in reimbursement levels between the two code ranges.

No matter which code is chosen, the actual work en-tailed when a neurosurgeon sees a patient for a consultation and then admits is often the same, states Michael W. Potter, MD, president of Cascade Neurosurgery and Spine Inc., and a practicing neurosurgeon for 19 years in Medford, Ore. Provided the requirements for a consultation are met, I would code for the consult and dictate a history and physical (H&P) because consultations reimburse at a higher level with my carriers.

Meeting the consultation code requirements becomes the issue. Codes 99241-99245 are for consultations provided in the physicians office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care or emergency department. To appropriately bill for a consultation according to CPT 2001, services must be requested by another physician or other appropriate source. The request cannot come from a patient or family member.

The following three elements are required for a consultation, advises Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with more than 50 specialties including neurosurgery, in Marshfield, Wis.:

Request from another physician (in this example the other physician is the ED doctor who called in the neurosurgeon);

Reason for the consultation services to be provided (medical necessity); and

Report that must be given to the requesting physician.

Note: The report should include findings, any treatments performed and a notation clearly stating whether the consultant will follow-up with the patient.

If the neurosurgeon was not called in for a consultation (because the patient was his own established patient whom the neurosurgeon admitted), or if the requirements for a consultation were not met, the admit codes would be the only option available. However, some insurance carriers say it is incorrect to code for a consultation if the physician asking the neurosurgeon for an opinion is not expecting to see the patient again. These carriers maintain that an ED doctor is transferring the care to the consulting physician and therefore only an admission code should be charged (even when the consultation requirements have been met).

This directive from certain carriers is in direct opposition to Medicare guidelines as defined in Section 15506 of the Medicare Carriers Manual (MCM), which states, In an emergency department in which the medical record is shared between the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physician/ER doctors progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry (e.g., a copy of the neurosurgeons note) in the common medical record. If a carrier refuses to pay for a consultation on the aforementioned grounds, use this information from the MCM to uphold the position that a consultation or an admission code is appropriate under these circumstances.

Be advised, however, that Medicare guidelines state that if a primary care physician (PCP) asks a neuro-surgeon to see his patient in the ED, it must be coded as a consultation.

Potter explains that some coders feel that if the requirements for either an admission or consultation have been met, the choice may come down to reimbursement. Depending on the state in which you practice and the carrier billed, an admission code may reimburse higher than a consultation or vice-versa. It is also important to note that admission codes have higher minimum requirements than consultation codes. If you havent documented at least a detailed history and exam, consultation codes would be your only option. Check your documentation and reimbursement levels and decide accordingly.

Appropriate Modifiers

When either a consultation or an admission code is billed at the same time as a surgery, carriers may attempt to disallow the E/M (consultation or admission) code. The explanation given by carriers is that the global surgery period begins the day before surgery, and therefore the decision to operate and all attendant E/M procedures performed are included in that period and are not separately reimbursable. Modifier -57 (decision for surgery) must be appended to the E/M service code to indicate the decision to perform the surgery was made during this encounter and so it should be separately reimbursable, states Susan L. Turney, MD, FACP, medical director of reimbursement for the Marshfield Clinic, Wis., and a representative to the AMA CPT Advisory Committee for the American Medical Group Association. However, for services with no global period (like 61107 or 61210), modifier -57 will not allow payment but modifier -25 will.

Some third-party carriers (such as certain workers compensation carriers) will only reimburse for E/M and trauma surgery claims when modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is added because they do not have up-to- date insurance software, says Nancy Timmons, CPC, a neurosurgery coding specialist at the Front Range Center in Ft. Collins, Colo. (Note: Modifier -25 was used to indicate decision for surgery prior to the creation of modifier -57.) Others, especially managed care systems, sometimes use in-house coding that has nothing to do with CPT or assigns meanings to codes other than what CPT prescribes. For this reason, it is crucial to ensure that your carriers are using up-to-date coding criteria and to find out what their requirements are. Timmons also says that detailed documentation is vital as it may help to bridge the communication gap with carriers that are not up-to-date.