Neurology & Pain Management Coding Alert

"Two distinct problems may plague professional coders who face the challenge of assigning proper codes during electroencephalographic (EEG) seizure monitoring, which include archaic diagnostic definitions and neglecting to code for signs and symptoms.

1. Archaic diagnostic definitions often frustrate coders who may be struggling to match the current medical terminology used by physicians in the patient record with the description published in the ICD-9 manual. Coders can mitigate this frustration by acknowledging the limitations of current diagnostic descriptionsparticularly within the series of epileptic seizure codesand assigning general ICD-9 codes that describe less specific types of seizure activity when appropriate.

2. Neglecting to code signs and symptoms and instead relying only on the final diagnosis may result in diminished reimbursement levels. Coders can counter this by remembering that the Health Care Financing Administration (HCFA) has ruled that it is acceptable for physicians to report signs and symptoms when the final diagnosis is not definite.

Using Epilepsy and General Convulsion Codes

Patients who suffer from seizures undergo EEG monitoring to pinpoint the reasons for the events and to help neurologists localize the portion of the brain affected. Under these circumstances, two of the most common codes used to describe seizures during EEG monitoring are 780.39 (other convulsions) or 345.9 (epilepsy, unspecified).

Generally, 780.39 is assigned to seizure activity that cannot be classified as epilepsy. If the patient suffers from epilepsy, however, there are several codes within the 345 series that may be appropriate.

Nonetheless, when you look at the diagnosis codes for epileptic seizures, it is very clear that they are completely out of synch with the manner in which modern epileptologists describe these symptoms, notes Robert J. Gumnit, MD, president of the National Association of Epilepsy Centers, which represents the largest comprehensive epilepsy centers in the United States and provides education to epilepsy programs, payers and the government. The codes are not consistent with how seizures are currently described in a patients chart. The best that a physician can do is provide a rough approximation of the diagnosis, as described in ICD-9, for the coder to assign.

Although the imprecise nature of the diagnosis codes is unfortunate, Gumnit points out that neither of these nonspecific codes has a negative impact on reimbursement levels. He adds that ICD-10, due to be published in 2003, is expected to improve the epilepsy codes to a degree, though not as completely as epileptologists would like.

Janell Behnke, medical business specialist for the Iowa Medical Society, agrees with Gumnit, but also notes that there are times when more precise epilepsy codes can be assigned. Sometimes, the neurologist is able to document identifiable forms of epileptic seizures as they are defined in ICD-9. For instance, seizures that can be described as petit mal (345.2) or grand mal (345.3) should be assigned the code that most accurately describes the epileptic event.

When that is the case, Gumnit stresses the importance of adding the fifth digit subclassification to the seizure code when possible. If we identify the epilepsy as intractablenot responding to ordinary doses of ordinary medicationthe diagnosis code should indicate it as such with 1 as the fifth digit (i.e., 345.31 grand mal status, with intractable epilepsy). If no intractability is mentioned, 0 would be entered as the fifth digit.

Code Signs and Symptoms

Other diagnostic categories that may be used to describe seizures include psychological or psychiatric disorders, Behnke says, although they may lead to reimbursement levels that fall short of the costs incurred for the EEG monitoring. This is less frequent, but occasionally we are able to diagnose seizures that are manifestations outside stress factors, like spousal abuse, for instance, she says. These may be considered pseudo-seizures and could be assigned a code from the ICD-9 300-series (neurotic disorders).

In assigning these codes as the primary diagnosis, neurology coders may inadvertently be shortchanging the provider, notes Gumnit, who also serves as president of MINCEP, an epilepsy center located in Minneapolis. While the final diagnosis is accurate, it does not always represent the signs and symptoms that required the EEG. For instance, we recently had a patient in status epilepticus who was airlifted 400 miles for monitoring. In the end, it was discovered that her seizures were not epileptic, and her neurologist diagnosed her as convulsive (780.39), with no other symptoms.

Ultimately, however, if the physician had found that the convulsion was due to severe psychological depression and had assigned that condition as the primary diagnosis code, the hospital would have received significantly less in reimbursement. This would not have been appropriate, since the signs and symptoms indicated that 780.39 would have been accurate and justifiable.

Gumnit adds that this is an error made all too frequently by providers and coding professionals throughout the countryand that coding signs and symptoms instead of a discharge diagnosis often poses a difficult dilemma for coders because they are trained to be as precise as possible. However, the medical community is beginning to realize that they are losing millions because the signs and symptomswhich substantiates the reasons for the testsare not documented.

Coding the Monitoring Procedure

The most common CPT procedural codes assigned to EEG monitoring of seizures are 95950 (monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic [e.g., 8 channel EEG] recording and interpretation, each 24 hours) and 95951 (monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic [EEG] and video recording and interpretation [e.g., for presurgical localization], each 24 hours). Both are ambulatory codes, with 95951 adding video recording to the monitoring function.

Code 95953 (monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic [EEG] recording and interpretation, each 24 hours) is a related ambulatory monitoring code, Gumnit reports, that is used to localize specific types of seizures. It is typically not assigned until routine EEGs or EEGs with video have been conducted.

Although Code 95950, 95951 and 95953 are used with patients exhibiting specific seizure activity, there is a series of codes that more frequently is assigned for EEG monitoring within the general populations codes 95812-95827. Of these, the most commonly used codes are 95812 (electroencephalogram [EEG] extended monitoring; up to one hour) and 95813 (greater than one hour), as well as 95816 (electroencephalogram [EEG] including recording awake and drowsy [including hyperventilation and/or photic stimulation when appropriate]) and 95819 (electroencephalogram [EEG] including recording awake and asleep [including hyperventilation and/or photic stimulation when appropriate]).

HCFA Allows Physician Practices to Code Symptoms Robert J. Gumnit" MD president of the National Association of Epilepsy Centers in Minneapolis notes that many neurologists may be losing significant reimbursement because coders do not understand when it is appropriate to code signs and symptoms rather than discharge diagnoses. This problem becomes even more apparent when coders dont realize that there is a very real difference between how hospitals and physicians may assign diagnostic codes " he says. The Health Care Financing Administrations (HCFA) regulations on coding point out that assigning codes for symptoms is appropriate and acceptable for physician reportingbut that this is contrary to coding practices used by hospitals and medical record departments for coding the diagnoses of hospital inpatients. HCFA offers the following example: Scenario: A neurologist evaluates a patient with complaints of dizziness and double vision. On physical examination" a visual field defect is noted. A diagnosis of rule out multiple sclerosis is made and the patient is referred for a magnetic resonance imaging (MRI). Multiple sclerosis (340) would not be coded as an established diagnosis. The physician should identify one of the signs or symptoms as the reason for the encounter (i.e. 368.2diplopia) and may list others as additional diagnoses if desired.

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