Neurosurgery Coding Alert

Billing for consultations that result in the decision to perform surgery can be challenging, especially when they take place in the emergency department (ED). Accordingly, it is imperative to choose the correct E/M code to describe the role of the neurosurgeon in this process. With the appropriate E/M code and the addition of the correct modifiers, you can increase reimbursement and decrease denials.

Choosing the Correct E/M Code

In a case that came from a Neurosurgery Coding Alert subscriber, a doctor was called in to see a patient in the ED who was in an automobile accident and suffered damage to her spine. The neurosurgeon decided that the patient needed to have surgery immediately. The patient was admitted to the hospital with the neurosurgeon listed as the admitting physician. A coding dilemma arose: Should a consultation (99241-99245) or admission (99221-99223) code be billed?

The decision is not easy because of several factors, including whether the requirements for a consultation have been met, whether the referral came from a primary care physician or an ED doctor, and state-to-state and carrier-to-carrier variations in reimbursement levels between the two code ranges.

No matter which code is chosen, the actual work en-tailed when a neurosurgeon sees a patient for a consultation and then admits is often the same, states Michael W. Potter, MD, president of Cascade Neurosurgery and Spine Inc., and a practicing neurosurgeon for 19 years in Medford, Ore. Provided the requirements for a consultation are met, I would code for the consult and dictate a history and physical (H&P) because consultations reimburse at a higher level with my carriers.

Meeting the consultation code requirements becomes the issue. Codes 99241-99245 are for consultations provided in the physicians office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care or emergency department. To appropriately bill for a consultation according to CPT 2001, services must be requested by another physician or other appropriate source. The request cannot come from a patient or family member.

The following three elements are required for a consultation, advises 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.:

Request from another physician (in this example the other physician is the ED doctor who called in the neurosurgeon);

Reason for the consultation services to be provided (medical necessity); and

Report that must be given to the requesting physician.

Note: The report should include findings, any treatments performed and a notation clearly stating whether the consultant will follow-up with the patient.

If the neurosurgeon was not called in for a consultation (because the [...]