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Neurosurgery Coding Alert

Reader Question ~ Most Second-Opinion Visits Are Not Consults

Published on Wed Jun 20, 2007

Question: Since CPT no longer carries the confirmatory consultation codes, how would I report the service when our neurosurgeon offers a patient a second opinion?

Illinois Subscriber Answer: If a patient comes to your practice and requests a second opinion, report the appropriate E/M code --" 99201-99205 for new patients and 99212-99215 for established patients.

For example, a new patient reports to the neurosurgeon for a second opinion regarding a proposed spinal condition treatment. Notes indicate that during the encounter, the surgeon obtained an expanded problem-focused history, provided a detailed exam and performed straightforward medical decision-making. On the claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the service.

Also: Physicians can send patients to the neurosurgeon for a second opinion. Report these visits with the appropriate E/M code as well.
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