Neurology & Pain Management Coding Alert

Eliminate payer guesswork with clear documentation

If you've ever filed a claim using an "unlisted-procedure" code, you know how much effort is involved. To ensure that your neurologist gets reimbursed for procedures without specific codes, our experts offer the following three pointers.

Tip 1: Describe the Procedure in Plain English

Anytime you file a claim using an unlisted-procedure code (for example, 64999, Unlisted procedure, nervous system; or 95999, Unlisted neurological or neuromuscular diagnostic procedure) you'll need to include a separate report that explains, in simple, straightforward language, exactly what the neurologist did.
 
Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Unfortunately, claims reviewers, especially at lower levels, do not have a high level of medical knowledge, and physicians don't always dictate the most accessible notes," he says. Part of the coder's job in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman's terms.
 
"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may even include diagrams or photographs to better help the insurer understand the procedure.
 
For example, CPT includes no specific code to describe electrosleep therapy, so  you should report the procedure using 95999. When describing the therapy, you should use the neurologist's operative notes as a guide, stressing the main points of the procedure. You may report, for instance, that "using electrodes placed externally on the patients head, the physician administered short-duration, low-amplitude pulses of direct current to the patient's brain" and include details such as "to treat chronic insomnia that has not responded to other treatments" to reinforce medical necessity.
 
"A little extra effort to write a clear description of the procedure can go a long way toward improving your reimbursement," Cobuzzi says.

Tip 2: Compare the Procedure to an Existing Code

An insurer will decide to pay an unlisted-procedure claim by reading your description of the procedure and comparing it to a similar, listed procedure with an established reimbursement value, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. Rather than leave it up to the insurer to determine which is the "next closest" code, you should explicitly make reference to the nearest equivalent listed procedure. "After all, the treating physician is best equipped to make this determination," Sandham says.
 
You should also note the specific ways that the unlisted procedure differs from the next-closest listed procedure, Sandham says. For example, was the claimed unlisted procedure more or less difficult than the "comparison" procedure? Did it take longer to complete? Was there a greater risk of complication? Will the patient require a longer recovery? Any of these factors can make a difference in the level of reimbursement you may expect.
 
For example, CPT does not include a code to describe qualitative sensory testing (QST). This test is similar to motor and sensory nerve conduction velocity tests (95900-95904) in that it measures function in both large-caliber nerve fibers. But QST differs in that the procedure also provides small-caliber nerve fiber testing. To report QST,
you may list 95999 and include an explanation with the claim stating, "Neurologist performed qualitative sensory testing, which is similar to nerve conduction testing, but provides additional data. The work involved was roughly 10 percent greater than that described by 95904 (Nerve conduction, amplitude and latency/velocity study, each nerve; sensory)."

Tip 3: Solicit Outside Advice

If the neurologist finds himself using equipment and techniques for which there is not a dedicated CPT code, you may be able to enlist the aid of the manufacturer in receiving appropriate reimbursement. Manufacturers often maintain free information and help lines to advise physician practices on how to approach insurers regarding new technologies. Use caution when applying manufacturers' suggestions, however.
 
Remember: You are responsible for the accuracy of your claims. You should never misrepresent a claim to gain payment. Stick to unlisted-procedure codes when no other codes describe the procedure the physician performed and always provide ample documentation to justify the necessity of the claim.
 
Payers will not always reimburse for an unlisted- procedure claim. Medicare policy specifically states that it will not reimburse for electrosleep therapy, for instance (although some third-party payers may reimburse for the procedure), but proper coding practice still dictates that you document and report all services provided, even when not paid.