Neurosurgery Coding Alert

Question: I work for a neurosurgeon in a solo practice. On occasion, he is called into the operating room during a surgical procedure by a surgeon of another specialty if a complication or unexpected finding occurs during surgery. In some instances it is necessary for the neurosurgeon to perform a procedure. Can we bill for an intraoperative consultation along with a surgical procedure in such cases, and if so, what procedure code would be appropriate? If the neurosurgeon does only an intraoperative consult and doesnt perform any surgery at that time, how do we code for his services?

Lake Geneva, Wis., Subscriber

Answer: In this situation, a neurosurgeon can bill for an intraoperative consult by using codes 99251 through 99255 (initial inpatient consultations) or 99241 through 99245 (office or other outpatient consultations), based on the documentation, and the request from the other surgeon must be in the patients chart, says Barbara Cobuzzi, MBA, CPC, CCS-P, a coding and reimbursement specialist in Lakewood, N.J. It can be difficult to bill for higher-level consultations because of problems meeting the examination requirements. History-taking can also be hard to report because patients are often unconscious, so the neurosurgeon should document history taken from the requesting physician or other source.

If the neurosurgeon performs a procedure after the consultation, either modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (decision for surgery) would have to be attached to the consult code, says Kathleen Mueller, RN, CPC, CCS-P, an independent surgery coding specialist in Lenzburg, Ill.

The neurosurgeon must always keep in mind the three Rs for defining a consultation: request, reason and response.

Request: The consultation must be requested by another physician or other appropriate source. An other appropriate source generally is viewed as a professional who can act on the advice given. If the patient accesses the specialist directly, it is not a consultation. This request must be documented in the patients medical record. If the requesting physician sends a note or card, place this document in the patients file. Otherwise, the neurosurgeon serving as consultant is responsible for documenting the request.

Reason: Medical necessity must be shown for the consultation services provided. This also must be documented.

Response: According to CPT 2000, the consultant must furnish a written report to the requesting physician (in addition to any operative note if the neurosurgeon performs a procedure). The report should indicate findings, any treatments performed, and if the consultant elects to follow the patient. A physician generally does not remain as a consulting physician except in the rare instances when there is a further specific request by the patients PCP. As per CPT 2000, If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patients condition(s), the follow-up consultation codes should not be used.