Neurosurgery Coding Alert

4 rules help you select between initial and subsequent visits

You can take control of your hospital care claims if you know when the neurosurgeon can claim an admission and when you must rely on subsequent care codes. Four  guidelines make your decision easy.

1: Claim an Admission for 'Total Care'

You may report a hospital admission (99221-99223) for a neurosurgeon (or any other specialist) as long as the neurosurgeon assumes full responsibility for the patient's care, says Mike Misko, a consultant with Practice Masters in Johnstown, Pa.
 
For example, from the emergency department the neurosurgeon admits a patient with head injuries. The patient may require the care of several specialists, such as a general surgeon, orthopedist, neurologist and others, to deal with his injuries, says Bob Burleigh, a consultant with Brandywine Healthcare Services in Malvern, Pa. As the admitting physician, the neurosurgeon would be responsible for the overall and ongoing care of the patient.
 
Only one physician can charge an admission: If two or more physicians co-manage a patient, you can only claim an admission for one physician. "You would never have multiple admitting physicians," Misko says.
 
In some cases, this means the attending physicians will have to decide among themselves who assumes overall care of the patient and therefore receives credit for the admission. Most trauma centers have protocols that outline which specialist will admit patients with multiple injuries (for instance, a trauma surgeon).
 
Insurers are watching: Several insurers have warned that specialists such as neurosurgeons often incorrectly bill for initial hospital visits. In many cases, the insurers argue, a neurosurgeon's first encounter with a patient in the hospital comes at the request of another physician and therefore more likely qualifies as a consult rather than an admission (see below).
 
The bottom line: If the surgeon manages only a single body system (such as dealing with a head or spinal injury), and a different physician oversees the remainder of the patient's care, the neurosurgeon cannot lay claim to the admission service. 

2: Co-Management = Subsequent Care

If two physicians co-manage a patient in the hospital, they should both bill subsequent care (99231-99233).
 
Payers sometimes deny simultaneous subsequent care claims on the grounds that the patient didn't need multiple visits, but with a specialist and a primary-care physician, or two specialists, "you can usually show there's medical necessity," especially for complex injury or illness or trauma cases, says Karen Jeghers, manager of Compliant Billing Services in Carver, Mass.
 
To claim subsequent care, the neurosurgeon should document that he has reviewed the patient's records, test results and status since the last assessment, says Jim Hugh, executive vice president at American Medical Accounting and Consulting in Atlanta.
 
In other words, all the normal E/M requirements exist for subsequent care. For a low-level inpatient follow-up (99231) this could include simple history or a problem-focused exam, and low-complexity medical decision-making, he says.

3: Watch for the 'Consult' Exception

 When the neurosurgeon sees the patient for the first time in the hospital, you may sometimes claim a consult (99251-99255) rather than an admission or subsequent care code. Keep in mind, however, that the rules for a consult are quite stringent, Jeghers says.
 
Specifically, a "consult" as defined by CPT describes a specific service involving three components: