Neurosurgery Coding Alert

Although Medicare and CPT have clarified their positions on consultation reimbursement, some neurosurgeons still have problems getting paid for them. By properly showing that the physician seeking the surgeons opinion requests only that and no transfer of care has occurred, neurosurgeons can ensure they are properly paid for the consultative services.

In August 1999, the Health Care Financing Administration (HCFA) issued transmittal No. 1644, clarifying the distinction between a new patient visit (99201-99205) and a consultation (99241-99255). This clarification proved necessary because many Medicare and third-party payers had been issuing denials or reductions for consultations when the consulting physician initiated any form of treatment, even if complete care for a presenting problem was not transferred to the consultant.

To throw further light on the subject, the CPT 2000 introductory text to the consultation codes was revised: A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patients medical record. The consultants opinion and any services that were ordered or performed must also be documented in the patients medical record and communicated by written report to the requesting physician or other appropriate source.

But even with the HCFA clarification and the revised CPT language, many neurosurgeons continue to report difficulties in gaining proper reimbursement for consultations. Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with more than 50 specialties including neurosurgery, in Marshfield, Wis., says that the use of the word referral in documentation related to consultations is one of the major problems.

Referral is an ambiguous term that is responsible for much of the confusion surrounding consultations, Fischer explains. She says that in medicine, refer means send, and it is widely used by physicians. But it is not in the CPTs introductory text for consultations, and with good reason. A physician may refer for treatment, refer for care, or refer for an opinion. Despite indications by the American Medical Association (AMA) that auditors should not view the word referral as an indication of a complete transfer of care for a particular condition, a red flag often is raised when auditors see this word in a physicians records, and initial consultation codes (99241-99245) often are denied or changed to new patient visits, which reimburse at a considerably lower rate.

Classifying a Transfer of Care

Eric Sandham, CPC, compliance educator for Central [...]