Neurology & Pain Management Coding Alert

Do not report a service without clear, necessary documentation. Instead, ask the physician for additional information. This may seem bothersome, but you'll save effort in the long run by avoiding rejected claims.

Example: Due to unfavorable patient reactions, the neurologist must re-adjust the parameters of a complex deep brain stimulator. The neurologist wishes to report 95978 (Electronic analysis of implanted neurostimulator pulse generator system ...; first hour) and +95979 (... each additional 30 minutes after first hour ...) for this time-consuming service. Although he records the parameters he adjusted, he fails to document the total time he spent.

Because 95978 and 95979 are time-based, the alarms should go off in your head immediately if the physician doesn't note the total time that he spent (or, even more helpful, the "start" and "stop" times). Without that kind of documentation, the claim won't stand a chance.

Solution: Go back to your neurologist and ask him to include a note in the patient record outlining the time he spent on the service.
 
The Top-10 Reasons Medicare Says 'No'

You can't correct your mistakes if you don't know what you're doing wrong. Here's a recent list of the most common problems CMS sees with the claims it receives

1. No documentation of service

2. No signature or authentication

3. Always assign the same level of service (LOS)

4. Consult versus outpatient/office visit

5. Invalid codes due to old resources

6. Unbundling of procedure codes

7. Misinterpreted abbreviations

8. No chief complaint listed/reflected

9. Global fee service billed separately

10. Inappropriate or no modifier used.

(Items in bold are discussed this issue. Look to next month's Neurology Coding Alert for more information on the remaining items.)

Learn more: CMS regularly updates its "top-10 denials" list. For more information, visit the Medicare Coverage Database on the CMS Web site www.cms.hhs.gov/mcd/indexes.asp. You can search for CMS articles, local coverage determinations and more by contractor, state or alphabetical listing.

Be proactive: "Try to make physicians aware of what is necessary to support a claim," Hammer says. "Most doctors want to practice medicine, not concern themselves with the details of billing and coding. To get the physicians on your side, make them aware that this is a dollars-and-cents issue. Tell them: 'Insurers won't pay without the appropriate documentation.' "

2. No Differentiation Between Consult/Office Visit

When reporting consults (99241-99263), you must remember to include documentation that differentiates the service from a standard office visit, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...)

A "consult," as defined by CPT, describes a very specific service that involves three components, says Annette Grady, CPC, CPC-H, healthcare consultant with Eide Bailly in Bismarck, N.D., and AAPC National Advisory Board member - all of which you must document to verify that the service the neurologist provided was, indeed, a consult. These include:

1. a Request from another physician for a consult. Ideally, this is a written request from the referring physician to the consulting physician, but at minimum you should have a note from the requesting physician in the shared patient record

2. an opinion Rendered by the consulting physician

3. a Report on the patient's condition sent by the consulting physician to the requesting physician.

Example: A primary-care physician requests that the neurologist provide a consultation for a patient complaining of neck (723.1, Cervicalgia) and shoulder (726.1x) pain.

The neurologist meets with the patient, conducts an exam and discusses possible treatment options. The neurologist prepares a report of her findings and sends them to the requesting physician. She recommends that the patient return for trigger-point injections.

In this case, you should report the appropriate-level consult because you have met the requirements of a request made, an opinion rendered, and a report sent.

Learn more: For complete information on consults, as well as how to deal with transfer of care issues, see "Make Sure That Consult Isn't a Transfer of Care (and Vice Versa)," Neurology Coding Alert, October 2004.

3. Obsolete Coding Resources

Even the best documentation won't help you if you're relying on obsolete coding information.

"Shelling out for a new CPT manual, ICD-9 manual and HCPCS manual every year may seem like an unnecessary expense, but really it's part of the cost of business for a medical practice," 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.

Codes and guidelines change every year, and even a single rejected claim could cost you more than the total expense of purchasing current code books.

Example: For 2005, CPT introduced two new codes for central motor evoked potential studies: 95928 (Central motor evoked potential study [transcranial motor stimulation]; upper limbs) and 95929 (... lower limbs).

But what if your neurologist provides these services and you're still working with a 2004 CPT manual? You'd probably report 95999 (Unlisted neurological or neuromuscular diagnostic procedure). Not only is this incorrect, but you're risking a rejected claim and possible audit troubles, as well.

Bottom line: If you're not using up-to-date resources, you're gambling with your reimbursement and compliance.

Next month: Four more ways to combat common Medicare rejections.