Neurology & Pain Management Coding Alert

Many factors determine the appropriate E/M service level for a given patient encounter. For instance, coexisting conditions can greatly influence the basic components of an E/M service (history, exam and medical decision-making, or MDM) which in turn may raise the encounter to a higher E/M service level. To receive the reimbursement to which they are entitled, physicians and coders must strive to list all diagnoses relevant to patient care for the services reported, because failure to document coexisting conditions properly often results in insufficient data to support the appropriate E/M code.

Physicians know that the type and severity of a patient's chief complaint influences the level of service provided. Similarly, the presence of pre- or coexisting conditions or other signs and symptoms may lead to increased risk to the patient, more (and more complex) data to be reviewed, the need for a more thorough examination and a generally higher level of MDM, advises Teresa Thompson, CPC, an independent coding and reimbursement specialist in Sequim, Wash. Coexisting conditions or new signs and symptoms may not be immediately apparent, and often reveal themselves during the history portion of the E/M service. Or, the information may come from the patient's

family or previous medical documentation.

For example, an established patient has been receiving periodic checkups for migraine (346.9x). During one such visit, the neurologist notices that the patient's speech is slightly slurred. Upon further questioning, the patient mentions various new symptoms, including tingling (782.0), difficulty swallowing (787.2), dizziness (780.4) and lack of balance, along with occasional vision problems (368.8). Recognizing these symptoms as potential indicators of MS (340), the neurologist decides that a thorough, updated patient history and complete examination are in order.

In this instance, a fairly straightforward visit is transformed into a level-five (i.e., 99215, Office or other outpatient visit for the evaluation and management of an established patient ) encounter. To establish medical necessity for such a comprehensive service the physician must document the signs and symptoms (e.g., 782.0, 787.2, etc.) that led to the decision to perform the exam, says Cathy Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. An established migraine diagnosis alone, for example, could not support such a high-level service.

Patients with a pre-existing MS diagnosis who seek treatment for a new problem, such as neuropathy (e.g., 355.9), may also require special attention. MS symptoms may go into remission, only to reappear suddenly. The disease's course is difficult to predict, and each new symptom must be evaluated to determine if it is the result of the MS or a distinct problem. Here again, the level of E/M service would be higher than that required for a patient without such complications. Similarly, the presence of other pre- or coexisting conditions, such as malignant hypertension (401.0), insulin-dependent diabetes (250.01), congestive heart failure (428.0) and respiratory or cardiovascular problems, may affect E/M levels. In all cases, proper documentation (a complete record of the preexisting condition) is required to substantiate a higher-level E/M service.