Neurology & Pain Management Coding Alert

When your neurologist performs a non-invasive test on a patient -- such as having the patient repeat a series of words or reciting the months of the year backwards -- has he performed a separately reimbursable service, or an included E/M? Recognizing the difference between neurobehavioral, neuropsychiatric, and E/M services can yield your practice proper Medicare reimbursement by following this checklist.

"Coders have to watch that our physicians are truly performing tests that are separately reimbursable and not included in the E/M service," says Lynn McCormack, CPC, with HCA Physician Services in Las Vegas.

Do not use 96116 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities], per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report) to report a mini-mental status exam (MMSE). "Many times I find that while wishing to code for 96116, diagnosis may support it but documentation may not," McCormack says. Code 96116 requires a minimum of the physician's time both face-to-face with the patient and preparing the report, McCormack says. While 96116 can be billed with modifier 52 (Reduced services) for less than one hour of time, it should not be confused with MMSEs that typically take only 10-15 minutes of physician time to perform and interpret.

A mini-mental status exam can be part of neurobehavioral testing, but an MMSE by itself is not reportable using 96116. When performed without additional neurobehavioral testing, report MMSEs with an appropriate E/M code, as these exams are considered part of an E/M service. When the MMSE is done as part of more extensive neurobehavioral testing, you may report 96116.

A neurologist may perform a neurologic test, but fail to adequately note the documentation required to substantiate it. When this happens, you should double-check with your physician to verify if a proper, reimbursable test was separately performed. "If the test was not documented, then the E/M service, if appropriately documented, is the only item billable," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, coding and compliance manager for UPMC-Surgery/Anesthesia.

In the absence of such documentation, you'll have to code only the E/M service (such as 99241-99245, Office consultation for a new or established patient ...).

The first type of test is a neurobehavioral exam. This test is administered to patients experiencing altered mental states, confusion, or cognitive difficulties as the result of stroke, brain injury, or various stages of Alzheimer's. If the test was done and documented, the documentation could support both the test and the visit, Berman says. The neurobehavioral exam is typically a series of questions or requests to perform certain actions performed by a clinician to assess the patient. These may include requests to repeat a series of words; list the months of the year backwards; or a series of directions to raise their right hand, then put their left hand on their right shoulder, then put their right hand on their left knee, then their left hand on their right ear, and so on.

Neurobehavioral status exam findings are often a precursor for the medical necessity or requirements for the more formal standardized neuropsychological testing. If your physician's notes indicate a neurobehavioral type of exam, then choose 96116.

Time-out: The code is based on time, so time spent must be explicitly mentioned in the report. According to the American Academy of Neurology, 96116 is for one hour of neurobehavioral testing, which includes the total time taken to administer and score the test, and to generate a report. There must be a separately identifiable report of the exam findings and interpretation included in your neurologist's documentation.

Per CPT Assistant November 2006, if the documentation indicates that time spent was less than one hour, but 31 minutes or more, you can still bill 96116. Time spent must include time spent face-to-face with the patient, interpreting test results, and preparing the report. Report services of 30 minutes or less with modifier 52 appended to 96116. Confirm with the individual payer as some have different policies for reporting partial hour time-based services.

Tip: You can still report an E/M service with 96116 as long as the neurobehavioral status exam is separate and distinct from the key components of the E/M service. Currently 96116 is bundled as a component of most E/M service codes. This National Correct Coding Initiative (NCCI) edit can be bypassed with a modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), to indicate to the payer that the physician performed the additional work.

The second type of test is the neuropsychological exam. These tests typically involve administration of standardized psychometric model tests in that the patient's quantitative results are compared to a normative sample group of peers.

Neuropsychological testing, such as the Halstead- Reitan Neuropsychological Test Battery, is used in the assessment and treatment of traumatic brain injury, dementia, neurological conditions, and psychiatric disorders. Neuropsychological testing is also an important tool for examining the effects of toxic substances and medical conditions on brain functioning. The battery also provides information regarding which part of the brain was damaged, whether the damage occurred during childhood, and whether the damage is getting worse, staying the same, or getting better. For this in-depth testing, use 96118 (Neuropsychological testing [e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test], per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report).

The diagnosis code(s) are determined based on your physician's findings as documented in the formal report. Many payers have coverage policies with limited diagnoses that meet medical necessity for  neuropsychology testing, so it is a good idea to check the payer for any coverage limitations prior to testing.

Clue: The standardized neuropsych testing involves a much longer testing time frame, often six hours or more. Again, some payers have limitations on the quantity of time allowed, so it is best to check prior to testing.