Neurosurgery Coding Alert

Don't report a consultation code unless you have a documented reason

For years you-ve known that in order to report a consultation code your neurosurgeon's documentation must satisfy the three R-s: request, render, and report. Now you-ll have one more R requirement to fulfill before you can successfully report a consultation: a medically necessary reason.

The Proof Is in the Details of Your Documentation

Without a documented reason for the consultation, you won't see any money for your physician's service. Make sure that the requesting physician specifies in the original consultation request why the patient needs the service before you report a consultation code.

In the past, your physician may have simply written -neurosurgical consult- at the top of his consult note when he performed a consultation at another physician's request. Instead, under the new guidelines, the neurosurgeon should write something like, -neurosurgical consult per internist's request,- and include the reason for the request.

-The medical record should indicate- if the physician requests a consult, CMS official Kit Scally said during the Jan. 20 physician Open-Door Forum. If a neurosurgeon meets another physician in the hallway and verbally requests a consult, both physicians should document that fact. If the neurosurgeon phones in the consult request to the other physician's staff, you should document that circumstance too, Scally said.

Avoid Unnecessary Pre-Op Clearance Requests

Since you have to provide a specific reason for the consultation, you won't be able to report presurgical clearance visits that aren't medically necessary as consultations, coding experts say. Your neurosurgeon will have to be careful when he asks another physician to perform a consultation and clear a patient for a surgical procedure. Without documented medical necessity, the consulting physician will be out of luck when he tries to capture reimbursement for the pre-surgery consultation.

When your neurosurgeon is planning surgery for a patient, it may not be uncommon for him to get a medical consultation from another physician as a preventive measure due to hospital guidelines or out of good general medical practice. In the past, the documentation for the consultation might have just said, -surgical clearance.- Now if your neurosurgeon doesn't identify some specific reason that the patient needs that surgical clearance, it will be considered a screening, not a consultation.

Example: A neurosurgeon refers a patient to an internist for medical clearance before a surgical procedure. There must be a documented medical reason, such as a heart condition, hypertension or diabetes, for why the neurosurgeon wants the internist to clear the patient for surgery.

Capture All the Details With a Standard Form

CMS has also made it clear that your neurosurgeon, as the consulting physician, needs to have a documented request in the patient's medical record, but the requesting physician now also has to include the request in the patient's medical record. You can't simply make sure the requesting physician's file has the consulting physician's report after the fact. The request for the opinion must be in the requesting physician's chart before the consult happens, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, NJ.

Tip: You may consider using ordering slips when your physician requests a consult and asking for a written request when a physician sends you a patient for your consultation. If a colleague regularly sends patients to your office, you should think about giving the requester ordering slips, similar to the ones radiologists and clinical labs use.

You can use a form that you can fax to the requesting physician's office, says Patricia Trites, MPA, CHBC, CPC, CHCC, CHCO, CEO of Healthcare Compliance Resources in Augusta, Mich. The requesting physician can keep this form in the medical record, which solves your documentation problems and also helps you accurately and clearly indicate the reason for the consultation request. (Look for a sample consultation request form in the next issue of Neurosurgery Coding Alert.)