Neurology & Pain Management Coding Alert

Because the Physician Fee Schedule assigns no physician work value to 37195 (Thrombolysis, cerebral, by intravenous infusion), you should report an appropriate E/M code, such as initial inpatient care (99221-99223) and initial and follow-up consultation (99251-99255, 99261-99263) when administering t-PA.

Due to the danger of secondary injury, individuals with stroke symptoms must receive immediate medical care preferably within three hours or less of the episode. If the neurologist admits a stroke patient to the hospital for immediate care, he or she can bill for initial hospital care (99221-99223).

According to CPT, initial hospital care codes "are used to report the first hospital inpatient encounter [i.e., visit] with the patient by the admitting physician." In many cases, the neurologist can justify a level-three service (e.g., 99223, Initial hospital care with comprehensive history, comprehensive examination, and medical decision-making of high complexity) for admission of a stroke victim, provided that documentation is complete. In all cases, the appropriate initial inpatient care code should be reported in addition to 37195 for t-PA administration.

Note that only one physician may use the initial codes per patient per hospital stay. If the neurologist tends to the patient following admission and E/M by another physician, he or she must report the subsequent hospital care codes (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) unless the specific requirements for a consult (discussed below) are met.

For initial consultations provided to stroke victims in either the emergency room or on the hospital floor, 99251-99255 (Initial inpatient consultation for a new or established patient ...) are appropriate. For necessary follow-up consultations, you may report 99261-99263 (Follow-up inpatient consultation for an established patient ...). Once again, these codes may be reported in addition to 37195.

To bill a consult properly, however, you must make sure the service meets three minimum requirements:

1. A request for a consult made by another physician or other appropriate source must be included in the medical record.

2. A reason for the consult must be documented in the medical record, i.e., medical necessity for the service must be demonstrated.

3. The consulting physician must prepare a written report of his or her findings that is provided to the referring physician.

Even if you meet the above requirements, some payers may reject consult claims if the language of the requesting physician is unclear. Therefore, physicians should avoid the terms "referral" and "consult and treat" 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 (i.e., a complete transfer of care has occurred), and therefore may not reimburse for a legitimate consultation.

A better choice when requesting a consult is to use language such as "Please examine patient and provide me with your opinion on his or her condition." Generally, however, the consultant has no control over the language used by the requesting physician. Therefore, the consultant has to make it clear in the chart and letter that only his or her opinion was requested and that a complete transfer of care did not take place, says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company.

Note, however, that the consulting physician may provide or initiate treatment (e.g., administer t-PA) as long as all consultation criteria are met and no transfer of care occurs, according to July 1999 HCFA (now CMS) transmittal, R1644.B3 (effective Aug. 26, 1999). The Medicare Carriers Manual, 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" ("referral," in this instance, is simply another term for transfer of care).

Next month: Proper reporting for t-PA with prolonged services codes +99356 and +99357.