Neurosurgery Coding Alert

Determining what constitutes a consultation as opposed to a referral or transfer of care remains a persistent coding challenge that requires specific expertise.

Meet Medicare Requirements

CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263) and confirmatory (99271-99275). When you bill a consult, section 15506 of the Medicare Carriers Manual (MCM) specifies that three guidelines (the Three R's) must be met:

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. 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.

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" when it is based on a personal encounter or phone call, or a patient statement of the primary care physician's request.

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

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

Any consult may be billed in addition to "any specifically identifiable procedure (i.e., a procedure with its own CPT Code ) performed on or subsequent to the date of the initial consultation," according to CPT. A physician may perform a consult for a patient he or she already knows or has treated, provided the above three criteria are met.

Select the Proper Consultation Type

Office or other outpatient consultation codes are assigned "to report consultations provided in the physician's office or in an outpatient or other ambulatory facility," according to CPT. A non-hospital-based physician may report a consultation given in the emergency department (ED) if the ED physician or other physician attending the patient requests it. The same physician may report more than one consult for the same patient (for either the same or a new problem), as long as the above three requirements are met on each occasion. Any subsequent office visits initiated by the consulted physician, however, must be reported as an office visit (99211-99215).

For example, says Laureen Jandreop, OTR, CPC, CCS-P, CPC-H, consultant-owner and trainer for A+ Medical Management and Education in Egg Harbor City, N.J., a patient presents to his or her primary care physician (PCP) with chronic low-back pain, spreading into the legs. The PCP documents the symptoms and requests a consult from the neurosurgeon. The neurosurgeon examines the patient and determines that further diagnostic testing, such as myelography, is necessary. The neurosurgeon prepares a report to the requesting physician, outlining his or her findings.

In this case, report the appropriate outpatient consultation code (9924x, as supported by documentation), along with the code(s) for any diagnostic tests (e.g., 722xx, depending on the myelography) performed. Subsequent visits by the same patient for the same problem would be billed with the appropriate office outpatient codes (9921x).

Initial inpatient consultation codes are used to report consultations provided for hospital inpatients and those in partial hospital settings or nursing facilities. The same physician may report only one inpatient consult per inpatient stay. Additional consults during the same inpatient stay should be billed using the follow-up inpatient codes. If the patient is discharged and readmitted later, however, another initial inpatient consult by the same physician may be reported if it is properly requested and documented.

Report follow-up inpatient consultation codes to complete the initial consultation or when the attending physician requests a subsequent consult during the same inpatient stay. These apply to established patients only. CPT further specifies that if the consulting physician initiates treatment at the initial consult and then participates in the patient's management, the subsequent hospital care codes, rather than the follow-up consult codes, should be used.

For example, the neurosurgeon receives a request to examine a bedridden patient in the hospital, arriving at a diagnosis of incapacitating sciatica caused by a displaced intervertebral disk (722.10). In this case, the appropriate initial inpatient consultation code (9925x) should be reported, along with any separate diagnostic procedure(s) provided.

The neurosurgeon does not assume responsibility for treating the patient, but receives a second consult request for the same patient during the same stay, either for the sciatica or a different problem. To report the second consult, use the follow-up consult code (9926x) best supported by the neurosurgeon's documentation.

Alternatively, if the neurosurgeon takes responsibility for treatment of the patient's condition after the initial consult, he or she should code follow-up visits using the appropriate subsequent hospital care code(s) (99231-99233).

If the same patient is then discharged and readmitted at a later date, and the neurosurgeon is again called upon to see him or her (whether for the same or a different problem) the initial inpatient consult codes should once again be reported.

Beware Transfer of Care and "Referrals"

In the past, some payers have not reimbursed consult codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans. In July 1999, HCFA (now CMS) transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult whether or not treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs. The MCM section 15506 further explains, "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."

If a transfer of care does occur, "The receiving physician would report a new or established patient visit, depending on the situation and setting (e.g., office or inpatient)," according to the MCM.

Note: A new patient is defined as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

For instance, in the above example involving the patient with low-back pain, the neurosurgeon may bill a consult even though he or she also performed diagnostic testing (or ordered additional procedures). These procedures/services do not constitute a transfer of care. Subsequently, however, the neurosurgeon may assume responsibility for treatment of the patient. These subsequent visits should be reported using the appropriate established outpatient codes (99211-99215). Only during a confirmatory consultation, in which a medical opinion alone is sought, must the physician refrain from initiating treatment.

In addition, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif., although the terms "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms when requesting or describing a consultation. Auditors and payers may automatically consider "referral" or "consult and treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming complete care of the patient, and therefore may not reimburse for a legitimate consultation.

Rules Differ for Confirmatory Consults

Medicare and CPT rules for confirmatory consultations those initiated by a patient or family, and not requested by a physician (reported by using 99271-99275) are much different from those for office or other outpatient (99241-99245), initial inpatient (99251-99255) and follow-up inpatient (99261-99263) consultations.

Confirmatory consults may be billed when an insurer or other physician seeks a second or third opinion, and may be provided in any setting. If an insurer requests the consult to determine medical necessity prior to covering treatment, report the appropriate code (99271-99275) with modifier -32 (Mandated services) appended.

In some cases, a patient may request the confirmatory consultation. When this occurs, there is no need for a documented request for the consult from a physician or other appropriate source in the patient's medical record. Note, however, that in this case the insurer is unlikely to reimburse for the service, and the patient should be billed directly.

In addition, unlike other types of consult, the physician may not initiate treatment during a confirmatory consult, only render a professional opinion regarding the patient's condition or diagnosis.

For instance, before allowing surgery for the patient diagnosed with sciatica, a third-party insurer seeks a second opinion from a different neurosurgeon. This second neurosurgeon evaluates the patient in the hospital, performing the necessary diagnostic tests. The session would be coded 9927x for the consult (depending on documentation), with modifier -32 appended. Any diagnostic tests should be reported separately (in this case, with modifier -26 [Professional component] appended because the hospital's equipment was used).