Neurology & Pain Management Coding Alert

Neurology practices can lose reimbursement opportunities or set themselves up for audits because of improperly coding E/M levels for established patients (99211-99215) with migraines (346.9x) as their primary diagnosis. Correctly applying the E/M code for a migraine depends on the usual key factors: history, exam and medical decision-making (MDM). However, MDM is the one that will determine how you code it.

Established Patient Scenario

An established patient with a well-established neurological history of migraines presents with a headache and nausea that are typical of his usual symptoms in both quality and intensity. Vital signs and a neurological exam are normal. He is given prescriptions for the symptoms and told to call the neurologists office if not better within four to six hours. The question is which E/M level to bill for this service based on the MDM.

Migraine headaches range from level three to level five depending on how they present. In the above scenario, although the history and exam are comprehensive, the MDM does not meet the level-five criteria because the neurologist knows the patients history, and thus that component is not of high complexity, says Cynthia Thompson, CPC, senior consultant and coding expert of Gates, Moore & Company, a medical practice management consulting firm in Atlanta.

Even with the best of documentation, I would code it at a level three (99213) unless a CAT scan or other testing were provided, Thompson explains.

Determining the Level of MDM

When coding by MDM, what propels an E/M to a higher level is how much work, time, thought, evaluation and risk are involved in the delivery of the service. The more documented effort and energy in each of these areas will lead to a better argument for coding to a higher level of service and being reimbursed at a greater rate.

The number of diagnosis or management options available to the neurologist also affects the MDM as well as the amount and complexity of data reviewed, says Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with over 50 specialties represented including neurology, in Marshfield, Wis.

The MDM here doesnt result in a level five because this is a patient who is well known to the neurologist, Fischer explains. It is not a new patient or a person who has never had a migraine before. The symptoms are exactly the same as they always are. In this case, the MDM does not involve concerns of a more serious problem, such as the neurologist asking, Is this a migraine or is it something worse? Are we worried about a subarachnoid hemorrhage or meningitis?

A level five visit, 99205 or 99215, for example, would normally be a patient who has no history of migraine or a patient whose migraines are suddenly different from the previous ones. If there is no established history of migraine or if the migraines have changed, the history, exam and MDM are going to start fresh so the neurologist might also order testing such as an MRI or CT scan, which would raise the level of MDM.

Understanding Medical Decision-making

Medical decision-making is important for evaluating and managing a patient. The neurologist carefully looks at all the facts concerning the patient and makes decisions regarding diagnosis and selecting a course of management as measured by:

the number of possible diagnoses and/or the number of management options that must be considered;

the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and

the risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

Once all the patients information has been reviewed and the MDM is finished, the neurologist can decide which of the four levels of MDM was met: straightforward, low complexity, moderate complexity or high complexity. To qualify for a given type of MDM, two of the three elements mentioned above must be met or exceeded. (See CPT 2001 E/M guidelines for specifics.)

Choosing an E/M Level

When choosing a level of E/M service for an established migraine patient, a neurology coder should keep in mind that insurance carriers have reports on the national percentages at which each E/M level is billed and also the percentages at which your office bills these E/M codes. If your E/M codes are above the national average for the higher-level codes, your office could be in danger of an audit. Make sure you have the documentation to back up every E/M choice, especially the higher-level codes, and dont always bill the same high level that may spark an audit as well because it is above the national average.

Medicares most recent comparison (1998) of neurology practices submission of E/Ms for established patients revealed the following percentages:

99211 1.4 percent
99212 8.5 percent
99213 41.9 percent
99214 38.5 percent
99215 9.7 percent

Note: A complete list can be obtained through the HCFA web site at www.hcfa.gov or the Journal of Neurology, volume 2001, issue 56, pages 586-591.