Neurology & Pain Management Coding Alert

Quick: What three requirements distinguish a consult (99241-99263) from other inpatient and outpatient E/M services? If you can't answer, you need to brush up on the "Three R's" of consults: request, reason and response.

Be Sure to Have a Written Request
 
  "As specialists, many of a neurologist's E/M services will be consults," says Anita L. Carter, LPN, CPC, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J. "Essentially, a consult takes place when one physician seeks the opinion or advice of a second physician, usually a specialist, for the treatment or diagnosis of a patient."

 Carter warns that the physician must meet three very specific criteria before you may claim a consult: "I won't even consider reporting a consult code unless the physician has documented the request, reason and report that distinguish a consult from a 'standard' office or hospital visit."

 This request is the first of the three elements that distinguish a consult from other E/M services. As explained by the Medicare Carriers Manual (MCM), section 15506, a consult must be "requested by another physician or other appropriate source" (except in the case of a patient- or insurer-generated confirmatory consult. See "Confirmatory Consults Follow Different 'Request' Criteria"  for more information).

 "The request should be in writing and documented in the patient's medical record," Carter says. "If a request isn't there, as far as the insurer is concerned a consult didn't take place." 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, according to the MCM.

 Any physician may request a consult from any other physician and may even provide a consult for his or her own patient as long as you follow all other guidelines (as outlined below). An "other appropriate source" generally means 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." But a school nurse, for instance, may not qualify, depending on the individual insurer's guidelines. If you have any doubts about what your payer considers an "other appropriate source," ask for its guidelines in writing.

Specifically State the Reason for the Visit

 In addition to a request, there must be a documented reason for the consult. "As with any service, the payer wants you to show medical necessity," says Kimberly Jawidzik, CPC, a coder with MedAssure LLC in Minneapolis. "The requesting physician should specify exactly why he or she is asking for a consult why it is required." For example, if a diabetic [...]