Internal Medicine Coding Alert

Many internists are confused about how to code dementia assessments for their geriatric patients because CPT does not provide a code for these encounters, but you can secure some reimbursement for your time by reporting the individual services performed during these comprehensive assessments.

"This is one of the areas that you will not get reimbursed for all the work involved," says Jan Rasmussen, CPC, president of the Eau Claire, Wis.-based Professional Coding Solutions. "You must bill for the components as provided."

Internists are increasingly being asked to provide these assessments, usually at the urging of family members who are concerned that an elderly patient's forgetfulness or other symptoms may affect his ability to care for himself.

The codes you use to report a geriatric dementia assessment will vary depending on the problems of the patient, but typically an assessment will include a comprehensive examination, mental/cognitive assessments, possible magnetic resonance imaging (MRI), computed tomography (CT) scanning or other imaging scans, and care planning after diagnosis, Rasmussen says.

You will likely code an initial visit for the evaluation and a follow-up visit after test results come back. Most internists will refer the patient out for some of the testing.

The first step in a geriatric dementia assessment is typically a doctor's examination. The physician will perform a physical, take a history and conduct a family interview to ascertain the behaviors such as forgetfulness or difficulty with daily tasks that prompted the assessment.

"Be sure to document signs, symptoms and reasons for the workup," Rasmussen says.

Code this visit using the appropriate office/outpatient E/M code. "The level you select is going to depend on what the patient's problems are," Rasmussen notes.

If the patient's only health problem is forgetfulness, you will likely use a lower-level code, Rasmussen says.

Most elderly people, however, have other health problems such as vascular disease, diabetes, hypertension, and often a history of stroke or heart attack and the physician must consider these health issues when assessing them for dementia, says John E. Morley, MD, director of the Division of Geriatric Medicine at Saint Louis University School of Medicine and editor of the Journal of Gerontology: Medical Sciences.

When a patient has multiple problems, the doctor will typically spend one to one-and-a-half hours completing the assessment and the visit's complexity may substantiate billing the highest-level E/M for an office visit (99205 for new patients or 99215 for established patients), Morley says.

The doctor performs a battery of tests such as a mini-mental status exam and a gait and balance assessment at this initial visit, in addition to the history, physical and family interview, Morley says.

"We roll all of that into the E/M," Morley says, because these tests do not have their own CPT codes.

The doctor often refers the patient out to a psychologist for neurocognitive testing in areas such as cognitive ability, memory, visual/spatial ability and language, says Phen Liem, MD, a board-certified geriatrician who is professor of geriatrics at the University of Arkansas for Medical Sciences in Little Rock. Coders typically report these assessments using a code from the central nervous system assessments/tests section of CPT for example, 96115 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning] with interpretation and report, per hour). Be sure to note that most payers reimburse for this code only when mental-health professionals perform extensive assessments and medical doctors cannot use it for mini-mental status exams.

The internist may order a variety of diagnostic tests at the initial encounter, depending on the patient's symptoms. Typically, these include blood tests, an MRI scan, and possibly a positron-emission tomography (PET) scan, Morley says. These tests will help pinpoint whether the patient's symptoms are caused by Alzheimer's disease (331.0), vascular dementia (290.4x), or another disorder.

When ordering tests to diagnose dementia, physicians must be careful to "document in the medical record the signs and symptoms associated with this," or the payer may not deem the test medically necessary, Rasmussen cautions.

Be sure that your diagnosis codes support the particular tests you are running. When billing Medicare, check your local medical review policies (LMRP) to determine which ICD-9 codes are covered diagnoses for the tests you run. For example, in Florida, First Coast Service Options considers diagnoses from the 290.0-290.9 range (Senile and presenile organic psychotic conditions) and the 330-334.9 range (Hereditary and degenerative diseases of the central nervous system), which includes Alzheimer's disease, as covered diagnoses for a CT scan of the patient's brain. But the carrier does not cover 290-290.9 for a brain MRI. On the other hand, Medicare carrier Palmetto GBA says that in Ohio and West Virginia, both 290.0-291.2 and 331.0-334.9 are covered diagnoses for an MRI of the brain.

Patients usually return for a second visit to learn the results of testing and to get counseling on the next step for treatment. Morley typically bills a level-four E/M code for this visit (99214). Although this visit is not as complex as the initial assessment, Morley says he often spends extensive time explaining the diagnosis and counseling the patient and family concerning the next steps. E/M rules permit you to base your code selection on time if you spend more than 50 percent of a face-to-face visit in counseling or coordinating care for the patient.

The physician may suggest that the patient see the nurse practitioner or a social worker for help in managing factors affecting the patient's well-being, such as remembering to take her diabetes medications. If these workers are on staff in the office, you may be able to bill these sessions with CPT codes 96150-96155, created in 2002 for health and behavior assessment/intervention by psychologists, social workers and other health professionals, such as nurses or nurse practitioners, Rasmussen says. CPT designed these codes to address bio-pscyho-social factors affecting patients with physical health issues.

Be sure to do your homework before using the 96150 series to make sure your Medicare carrier accepts these codes. The Florida carrier First Coast Service Options lists the 96150 series as noncovered.

Also note that physicians cannot use these codes but instead should use E/M codes when they provide similar services, the CPT manual states.