Neurosurgery Coding Alert

Question: On occasion, a patient with radicular pain and an MRI with positive findings will be sent to the neurosurgeon by a PCP without a written request or other contact. If the neurosurgeon sees the patient, completes the assessment, recommends surgery and follows through with the plan, should this be coded as a referral or a consult?

Wisconsin Subscriber

Answer: In this case, the neurosurgeon has accepted a self-referral, which is reported using the new patient visit codes 99201-99205, as appropriate.

To bill a consult (99241-99275), you must meet three guidelines (the Three R's) from section 15506 of the Medicare Carriers Manual (MCM):

1. Request: A consult is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

According to the MCM, "In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request ... may consist of an appropriate entry in the common medical record." In an office setting, there must be a specific written request for the consultation from the requesting physician, or the consultant's records "must show a specific reference to the request."

Any physician may request a consult from any other physician. An "other appropriate source" is generally understood to mean any individual who can act on the advice/information provided by the consulting physician. According to the MCM, "Limited licensed practitioners, e.g., nurse practitioners or physician assistants, may request a consultation." A school nurse, for instance, may not qualify, depending on the individual carrier's guidelines. Check with the insurer if there is any doubt that an appropriate source has requested a consult.

2. Reason: A request for a consultation from an appropriate source and the need for consultation (medical necessity) must be documented in the patient's medical record. In other words, there must be some indication or symptom that prompted the need for an opinion.

3. Response: After the consultation, the consultant must prepare a written report of his or her findings, which is provided to the physician who sent the patient.

MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician."

In this case, the above conditions have not been met. The visit should be billed as a new patient service. This would not technically be a "referral" because the neurosurgeon must accept the transfer of care in advance to properly use that term to describe it.

Note: According to the MCM section 15506, "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" [emphasis added].

If the patient is under the care of a primary-care physician (PCP), the neurosurgeon may want to send a letter of inquiry as to whether he or she is being requested to "consult and treat" the patient. If the neurosurgeon receives an affirmative reply, he or she may treat the service as a consultation as long as a response is returned to the PCP, as outlined in the above guidelines. Some risk-management experts recommend that specialists see patients only in consultation with a PCP, to avoid legal responsibility for the patient's complete medical care.