Internal Medicine Coding Alert

Questions:(1) During a physical exam of a patient
who presents with occasional episodes of confusion and
forgetfulness, a mini-mental status exam is performed.
May a code be used in addition to the appropriate level of
E/M service for the test?

Visalia (CA) Medical Clinic

(2) One of our doctors does a mental assessment on patients if he thinks that they may have had a stroke, have early signs of dementia, or if they complain of confusion. Its a mini-mental check or status test, which is a set of questions with a score to assess. I cannot get this paid psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communications). Any suggestions?

Charlottesville (VA) Family Medicine

Answer: Getting paid separately for a mini-mental status exam is one of the most common myths in coding folklore, says Callaway-Stradley.

The exam, while clinically useful, is just a tool to
perform a comprehensive neurological examination,
according to the 1997 Evaluation and Management
Documentation Guidelines. Therefore, performance of this
service is included in the overall evaluation and management (E/M) code for the visit, she adds.

Apparently there are a number of pharmaceutical
sales representatives giving these forms to primary-care
physicians, selling it as a way for them to make loads of
money, Callaway-Stradley says. But, its not a separate
service.

If internists look closely at the form or at the exam
performed by the physician, they should notice that it is
basically ensuring that the patient is oriented to date, time, and place and has basic recall and calculation skills.

It is almost verbatim the bullet items from the
comprehensive neurological workup from the 1997
guidelines, she says.

The entire exam will probably fall under the
neurological section, explains Callaway-Stradley. Internists should remember that they get to pick
whichever exam format they want, based on the patients
condition. You dont always have to use the guidelines for
the General Multi-System Exam just because you are the
primary-care doctor.

The most common code that Stradley sees reported
erroneously for this service is 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).

This code should be used when the physician performs
special neurological testing, not a brief check, she
continues. A clue in the code definition is that it states
that it should be reported per hour, she adds. A mini-
mental check usually takes about 10 to 20 minutes.

The mini-mental-status is a neurological exam,
which includes a psychiatric component, but you are not
doing any special testing, Callaway-Stradley emphasizes. What these codes (96100-96117) are about is special testing, when the physician has determined that something is wrong and needs to look further.

The other code suggested here, 90802 also is incorrect.

That is a complete psychiatric interview, Callaway-
Stradley says. It is performed because the patient cannot
communicate at all with the interpreter and because of
that they cannot talk to the interviewer. It is used for kids or for adults who truly cannot communicate for whatever reason. You are talking about an hour-long exam. It is not a mini-mental-status exam.

In fact, according to the local coverage policy for
Cahaba Government Benefits Administrators Inc., the
Medicare carrier for Georgia, that code is paid only
when the patient is younger than 16 years of age, or when an adult patient is incapable of communicating verbally with the physician.

Procedure 90802 is described as being used
principally by child psychiatrists, psychologists and
clinical social workers when they initially evaluate
children who do not have the ability to interact with
ordinary verbal communication the policy states. This
code may also be applied to the initial evaluation of adult
patients with organic mental deficits, or who are catatonic
or mute.

The Interactive Medical Psychiatric Diagnostic
Interview Examination (90802) includes the same
components as the Psychiatric Diagnosis Interview
Examination, which includes history, mental status,
disposition, and other components as indicated. However,
in the interactive examination, the physician uses
inanimate objects, such as toys and dolls for a child,
physical aids and non-verbal communications to overcome
barriers to therapeutic interaction, or an interpreter for a deaf person or one who does not speak English.

Procedure code 90802 is covered for the interactive
evaluations of children who are 16 years of age or
younger, and of adults, who have one of the following
conditions, as classified in the ICD-9-CM (1996);

295.20-295.25Schizophrenic disorders; catatonic type.

299.00Psychoses with origin specific to childhood;
infantile autism, current or active state.

299.80Psychoses with origin specific to childhood;
other specified childhood psychosis, borderline psychosis of childhood.

Clearly, the code is not intended for use with a brief
mental status check of a patient, says Stradley.

Primary-care physicians should keep in mind that
a mini-mental check does often constitute the compre-
hensive level of a neurological E/M exam, according to the 1997 Guidelines. If the workup was the primary service at the visit, then the physician can bill an appropriate level of E/M.