Neurology & Pain Management Coding Alert

Providers often pay little attention to confirmatory consultation codes (99271-99275), but with the U.S. Office of Inspector General (OIG) once again targeting E/M services and consults in particular for increased scrutiny in 2003, physicians and coders must use extra caution to report such services accurately. By carefully documenting the confirmatory nature of the consultation and appending modifiers as appropriate, you can greatly increase your claims' accuracy and the odds of receiving reimbursement for payer-mandated services. What Makes a Consult Confirmatory? A confirmatory consultation is a lot like any other inpatient or outpatient consultation (99241-99263), with a few important differences. "The primary difference between a confirmatory consult and a 'run-of-the-mill' consult is that during a confirmatory consult the physician is offering a second or third opinion, either to concur or to disagree with the advice, opinion or diagnosis provided by another physician, often of the same specialty," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "In contrast, during a 'normal' consult a physician refers the patient to a different physician, usually with more specialized knowledge. In this case, the consulting physician is offering a 'first' rather than a 'second' opinion."

Another distinguishing feature of a confirmatory consult is that a patient, a member of the patient's family or an insurer can request the service, whereas only a physician or "other appropriate source" (that is, a medical professional) can request an inpatient or outpatient consult as described by 99241-99263. In other words, if a patient (or family member, insurer, etc.) wants a second opinion before proceeding with treatment or a major diagnostic procedure or accepting a diagnosis, the patient can request a confirmatory consult without the intervention of a physician. In fact, for billing purposes, confirmatory consult codes are reserved for a second opinion generated by a nonphysician or nonbilling provider only, says Carol Pohlig, BSN, RN, CPC, reimbursement analyst and senior coding and education specialist in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. In all cases, the consulting physician must be aware of the confirmatory nature of the opinion sought. As noted in CPT, you may provide a confirmatory consult in any setting (inpatient or outpatient) and should expect to provide an opinion or advice only. Like other consultations (and all E/M services), you must choose the appropriate level of confirmatory consult according to the key components of history, examination and medical decision-making although time may become the primary factor if more than 50 percent of the visit is spent in counseling and coordination of care. If you do assign a code based on time, you must [...]