Neurology & Pain Management Coding Alert

 
Consultation codes are chosen using the same criteria as other E/M codes. With the exception of the follow-up codes 99261-99263 -- which apply only to previously seen patients -- consult codes (99241-99255 and 99271-99275) may be used for both new and established patients. All of the three key areas of history, examination and medical decision-making (MDM) must meet or exceed the requirements of the level chosen.
 
History may be either problem focused, expanded problem focused, detailed or comprehensive, as follows:
 
Focused -- chief complaint, brief history of present illness (HPI)
 
Expanded focused -- as above, but including problem-pertinent system review (i.e., review of at least one item in the "system review" portion of the CPT introduction to the Evaluation and Management (E/M) Services Guidelines)
 
Detailed -- as above, with extended HPI, problem- pertinent system review extended to limited number of additional systems and a pertinent past, family and/or social history (PFSH) directly related to the presenting problem
 
Comprehensive -- as above, with review of systems directly related to problems in HPI, plus all additional systems and a complete PFSH.  
The examination may also be either problem focused, expanded problem focused, detailed or comprehensive:
 
Focused -- limited exam of affected body area or organ system
 
Expanded focused -- as above, plus other symptomatic or related organ system(s)
 
Detailed -- as above, with extended examination of affected body area(s)
 
Comprehensive -- general multisystem exam or complete exam of a single organ system.  
MDM is defined as either straightforward, low complexity, moderate complexity or high complexity:
 
Straightforward -- a minimal number of possible diagnoses and/or management options, minimal or no amount/complexity of data and minimal risk of complications, morbidity and/or mortality
 
Low complexity -- a limited number of possible diagnoses and/or management options, a limited amount/complexity of data and low risk of complications, morbidity and/or mortality
 
Moderate complexity -- multiple possible diagnoses and/or management options, a moderate amount/complexity of data and moderate risk of complications, morbidity and/or mortality
 
High complexity -- an extensive number of possible diagnoses and/or management options, an extensive amount/complexity of data and high risk of complications, morbidity and/or mortality.  
To qualify for a given level of MDM, two of the three requirements for that level must be met or exceeded. According to CPT, "Co-morbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision-making."
 
Note: See charts on the back of this page for the requirements of each level and type of consultation.
  
Coding Examples  
For instance, 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., at the request of the primary care physician (PCP), a patient presents to the neurologist's office for a consultation. The patient [...]