Neurosurgery Coding Alert

Determining what constitutes a consultation as opposed to a referral or transfer of care remains a persistent coding challenge that requires specific expertise. Meet Medicare Requirements CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263) and confirmatory (99271-99275). When you bill a consult, section 15506 of the Medicare Carriers Manual (MCM) specifies that three guidelines (the Three R's) must be met:

1. Request: A consult is 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. Any physician may request a consult from any other physician. An "other appropriate source" is generally understood to mean 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." A school nurse, for instance, may not qualify, depending on the individual carrier's guidelines. Check with the insurer if there is any doubt that an appropriate source has requested a consult. 2. Reason: A request for a consultation from an appropriate source and the need for consultation (medical necessity) must be documented in the patient's medical record. According to the MCM, "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." In an office setting, there must be a specific written request for the consultation from the requesting physician, or the consultant's records "must show a specific reference to the request" when it is based on a personal encounter or phone call, or a patient statement of the primary care physician's request. 3. Response: After the consultation, the consultant must prepare a written report of his or her findings, which is provided to the referring physician. MCM guidelines further specify that the consultation report must be "a separate document communicated to the requesting physician" [emphasis added]. Any consult may be billed in addition to "any specifically identifiable procedure (i.e., a procedure with its own CPT Code ) performed on or subsequent to the date of the initial consultation," according to CPT. A physician may perform a consult for a patient he or she already knows or has treated, provided the above three criteria are met. Select the Proper Consultation Type Office or other outpatient consultation codes are assigned "to report consultations provided in the physician's office or in an outpatient or other ambulatory facility," according to CPT. A non-hospital-based physician may report a consultation given in the emergency department (ED) if [...]