Neurology & Pain Management Coding Alert

Coding expert Nicoletti weighs in with her advice Don't allow your practice to lose money over consult and referral coding. Let Betsy Nicoletti, CPC, a consultant with Helms & Company, a physician practice management company in Concord, N.H., answer the top nine coding questions for this service:  Question 1: Why is correct coding for consultations important? Answer: First, we all want to optimize revenue, and we are paid more for consultations than for new patient visits. Consultations are also on the HHS Office of Inspector General's Work Plan this year and have been for the past few years. It certainly got my attention about a year ago when I was visited by two men in suits who flashed their badges at me. One was from the Office of Inspector General, and one was from the U.S. Department of Justice, coming to talk to me about a physician and his consultation code use. So to legitimately and ethically bill for that service and be paid at that higher level, you must know the appropriate criteria of a consultation.  Question 2: What are consultations? Answer: Consultations are the E/M services that we find in the beginning of the CPT book. They are broken down into office and outpatient consultations (99241-99245), initial inpatient consultations (99251-99255), follow-up inpatient consultations (99261-99263), and confirmatory consultations (99271-99275).  Question 3: Does Medicare define consultation differently than the CPT? Answer: Yes, and basically the difference is based on who can request a consultation. Medicare specifically states that only a physician, a nurse practitioner, a physician assistant or a certified nurse midwife may request a consultation. That means a social worker, a physical therapist and a nurse are not people who can legitimately request a consultation for a Medicare patient and have the consulting physician bill and be paid for a consultation.
 
The CPT definition, which some third-party carriers may adhere to, lists the same group as Medicare in addition to "another appropriate source," which may include physical therapists, occupational therapists, speech therapists, psychologists, social workers and even lawyers. When dealing with third parties, I assume they are going to use CPT rules unless I hear otherwise.
 
Medicare makes no distinction between new and established patients for a consultation, so you can provide a consultation for an established patient as long as you meet the proper criteria.
 
Neither definition allows a self-referral for a consultation. A self-referral is billed as an office visit or hospital visit or whatever the appropriate type of service is, but not as a consultation.  Question 4: What are Medicare's criteria for billing a consultation rather than a visit? Answer: To distinguish between a hospital visit, admission, emergency department visit, new or established patient visit or any of [...]