Neurology & Pain Management Coding Alert

Reduce denials for your practice by reading the fine print.

There are always a few tricky codes out there that can cause denials from carriers. Take a few minutes to test yourself against these quick, easily solved issues to reduce compliance errors.

Scenario: Your neurologist performs a sleeping or comatose EEG in the hospital ICU with a facility's equipment. You should use 95822 (Electroencephalogram [EEG]; recording in coma or sleep only) and append modifier 26 (Professional component).

Common mistake: Some coders might mistakenly report the diagnostic study without any modifiers. But EEG code 95822 is made up of two components: the technical component (modifier TC) and the professional component (modifier 26).

TC is for the person or facility which actually owns the equipment, says Peggy Stilley, CPC, office manager for an Oklahoma University-based private physician practice in Tulsa. The 26 modifier is for the professional interpretation.

If your neurologist performs a sleeping or comatose EEG with a facility's equipment, you should use 95822 and append modifier 26 to reflect that he provided the professional component only -- meaning he interpreted the findings and wrote the report.

Reminder: Use these modifiers only on procedures having both the professional and technical components. You should not use modifier 26 with procedures that are either 100 percent technical or 100 percent professional. But for codes that have technical and professional components, reporting the global service -- that is, failing to append modifier 26 -- when the facility bills with modifier TC means the technical portion of the service will have been double-billed. This can potentially lead to a demand for repayment or accusations of billing fraud.

Play it safe: Medicare will not pay physicians for the TC of services provided in a facility setting, such as inpatient (POS 21) or an outpatient hospital (POS 22) setting. Often, the Medicare carrier will deny processing and the physician will need to resubmit a corrected bill with modifier 26 appended.

When you report locum tenens (stand-in physician) services, should you add modifier Q5 (Servicefurnished by a substitute physician under a reciprocal billing arrangement) to the report?

Watch your step: When you report locum tenens services, don't confuse modifier Q6 (Service furnished by a locum tenens physician) with reciprocal billing modifier Q5. Reciprocal billing arrangements typically describe a two-way exchange between providers, says Kelly Dennis, MBA, CPC, ACS-AP, in Leesburg, Fla.

For example: Your physician and another neurologist in town agree to see each other's patients on weekends off and agree to a reciprocal billing agreement. These services would fall under modifier Q5. In these situations, the doctor who "owns" the patients, not necessarily the one who saw them at those visits, bills out the provided services under his national provider identifier (NPI) and appends modifier Q5 to indicate he really did not see the patient. The physicians don't exchange any money because the services even out over time.

By comparison: Locum tenens describes a one-way exchange between providers. Your physician would retain a substitute neurologist to take over the practice for such reasons as illness, pregnancy, vacation, or continuing medical education. The substitute neurologist generally is paid a fixed amount per diem or similar for-time basis. To report the locum tenens services, you would append modifier Q6 to all of the temporary neurologist's claims and bill under your physician's (who the locum is replacing) NPI, Dennis says.

Medicare will only allow a locum tenens to provide services to Medicare patients for a 60-day continuous period. The continuous period countdown begins with the first day the substitute neurologist provides covered services and continues without interruption, even on days when no services are provided to your patients.

Here's the scenario: Your neurologist administers an EEG that lasts for 25 minutes. You check the documentation and find that during the testing, the patient came close to losing consciousness, but she never actually fell asleep. In this situation, is your correct coding choice 95819 (Electroencephalogram [EEG]; including recording awake and asleep)?

Check your answer: Since the scenario states that the patient didn't fall asleep, you should submit 95816 (Electroencephalogram [EEG]; including recording awake and drowsy).

Coding EEG tests depends heavily on correct physician documentation. There can be a fine line between "drowsy" and "asleep," but you can report 95819 only if documentation notes that the patient fell asleep.

Stick to the rules: Resist any temptation to consider 95819 as legitimate if your neurologist intended to conduct a sleep study but the patient did not actually fall asleep. Experts note that billing based on a physician's "intention" can create significant compliance issues. Code and bill only the procedures the providers performed and documented.